7.12 First Nations Health Benefits (Plan W)

[September 8, 2021: Removed pharmacist-initiated OTC list, enabling pharmacists to recommend and initiate therapy from the entire Plan W OTC Drug formulary]

[March 3, 2020: Removal of Non-Insured Health Benefits]

[June 10, 2019: Updated description of coverage for over-the-counter (OTC) medications]

[April 1, 2019: Revised age of infants eligible for Plan W benefits via parents’ registration under the Indian Act]

General Policy Description

Plan W covers eligible prescription drugs, certain over-the-counter (OTC) medications, and some medical supplies/devices for eligible members of the First Nations Health Authority (FNHA).

Policy Details

Coverage is provided for individuals.

An individual must:

  • Have active BC Medical Services Plan (MSP) coverage, and
  • Be a registered Indian under the Indian Act, or be a child under 24 months of age, who has at least one parent who is a registered Indian under the Indian Act, and
  • Not be an individual eligible to receive comprehensive drug coverage through
    • a treaty and land claims agreement under the Constitution Act, 1982 (Canada) (unless that treaty and land claims agreement has been identified by the provincial Minister of Health as not resulting in ineligibility), or
    • a written contribution arrangement between a First Nations organization and a government or province of Canada under which the government provides funding and which has been identified by the provincial Minister of Health as resulting in ineligibility for enrolment

PharmaCare cannot authorize Plan W coverage; eligibility for the plan is confirmed by the FNHA.

Under Plan W, PharmaCare pays 100% of

  • Eligible prescription drug costs up to the maximum cost recognized by PharmaCare
  • Certain over-the-counter medications and devices
  • Dispensing and pharmacy services fee costs up to the maximum fee recognized by PharmaCare
    Note: There is no dispensing fee for non-drug over-the-counter items
  • Plan W benefits purchased within Canada but outside B.C. if a request for reimbursement is submitted with appropriate documentation

FNHA confirms eligibility, and Plan W coverage is automatically uploaded to PharmaNet. Coverage is in effect from the time the individual’s eligibility for Plan W is uploaded to PharmaNet.

Plan W coverage cannot be provided retroactively.

Covered under Plan W

For an OTC drug in the Plan W OTC drug formulary to be eligible for coverage:

Note: Insulin products are excluded from this policy. Insulins can be dispensed and the claim entered on PharmaNet without a prescription or the Plan W OTC Recommendation form (refer to section 5.14 of the PharmaCare Policy Manual).

>> See the list of Plan W OTC Drug Benefits (PDF, 766KB). A prescription or a completed Plan W OTC recommendation form is required for all listed products.

>> HLTH 4571 - Plan W OTC Recommendation form (PDF, 932KB)

Covered under Plan W

PharmaCare covers specific devices under Plan W at their retail price up to a maximum set by FNHA, with no dispensing fee. (See Section 5.9 – Retail Pricing Policy).

Claims for devices covered by PharmaCare automatically adjudicate under Plan W.

Please see the list of Plan W Non-Drug OTC Benefits PINs.

Specific medical supplies and equipment (MS&E) for FNHA clients are covered through FNHA’s private insurer.

>> See the list of FNHA MS&E benefits.

PharmaCare covers certain supplies under Plan W at the retail price, with no dispensing fee.

>> See the list of Plan W Non-Drug OTC Benefits PINs.

For individuals newly diagnosed with diabetes, who are covered under the First Nations Health Benefits (Plan W), FNHA covers the first fill for blood glucose test strips (BGTS), providing the BGTS are a PharmaCare benefit. For issues concerning coverage of BGTS for Plan W clients, contact the First Nations Health Benefits team at 1-855-550-5454.

Out-of-province purchases of Plan W benefits may be reimbursed if the client submits an HLTH 5480 - Out-of-Province claim form (PDF, 92KB) to PharmaCare with the appropriate documentation.

 

Procedures for Pharmacists

 

Plan W coverage not in place

Occasionally, the FNHA client eligibility may not have been uploaded to PharmaNet, and the PharmaNet transaction will not provide the expected adjudication results.

  1. In this case, call the PharmaNet Help Desk.

    The Help Desk will attempt to confirm active Plan W coverage. If coverage is confirmed, the Help Desk enters the coverage in PharmaNet to allow for the prescription to be processed under Plan W.
     
  2. Once you receive confirmation that short-term assistance is in place, process the prescription as usual.
  1. Enter the claim in PharmaNet as you would any other prescription; and
  2. Retain a copy of the prescription on file.
  1. Complete the HLTH 4571 - Plan W OTC Recommendation form (PDF, 932KB).
  2. Enter the claim with P1 (for College of Pharmacists of BC) in the PRACT ID REF field and your own College Registration Identification (Reg ID) in the Prescriber ID field; and
  3. Retain a record of the purchase similar to that required for prescription items.

 

Tools and Resources

For questions regarding eligibility for Plan W, clients and pharmacists can contact FNHA at 1-855-550-5454 or by email at HealthBenefits@fnha.ca.

For questions regarding PharmaCare Plan W coverage and claims:

Resources: