7.12 First Nations Health Benefits (Plan W)

General Policy Description

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

Policy Details

Eligibility

Coverage is provided for individuals.

An individual must:

• Have active BC Medical Services Plan (MSP) coverage, and
• Be registered under the Indian Act, or be a child under 24 months of age, who has at least one parent who is registered 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.

What is covered?

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

Coverage start date

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.

Over-the-counter (OTC) medications

Plan W OTC drug benefits are eligible for 100% coverage when the claims are entered in PharmaNet, subsequent to:

• A prescriber (e.g., a physician, nurse practitioner) writing a prescription, or
• A pharmacist recommending an OTC treatment:
  • As part of a Minor Ailments and Contraception Service (MACS) assessment. The pharmacist must document the recommended OTC treatment on the MACS Form. In this case, the Plan W OTC Recommendation form is not required
  • Outside a MACS, the pharmacist must complete the Plan W OTC Recommendation form (PDF, 548KB) or their own form that captures the same information

Pharmacists can dispense a Plan W OTC item recommended by another pharmacist. They enter the recommending pharmacist's College Registration Identification (Reg ID) in the prescriber ID field.

For every OTC item dispensed under Plan W, the dispensing pharmacy can claim the maximum dispensing fee and mark-up covered by PharmaCare. 

The dispensing pharmacy must retain a record of the OTC Recommendation form, the MACS Form or prescription, and consult with the client following requirements outlined under the Health Professions Act, Bylaws Schedule F, Part 1 section 11(2), (3) and (4), and section 12, and the Pharmacy Operations and Drug Scheduling Act (PODSA) Bylaw section 23(1)(a), (2), (3).

Supporting FNHA clients with accessing OTC drug benefits is a component of culturally safe pharmacy care. Pharmacists are expected to explore Plan W OTC medications and provide a covered product when in the best interest of the client. Should a pharmacist decide to not recommend and/or provide an OTC drug benefit requested by an FNHA client, they should discuss therapeutic options and advise the client to seek further care as appropriate.

Frequency of dispensing

PharmaCare will not reimburse pharmacies for dispensing fees when a Plan W OTC is prescribed for daily and/or frequent dispensing.

Audit

Plan W OTC claims are subject to audit by the Ministry of Health and the First Nations Health Authority, and any amount associated with a disallowed claim will be recovered.

OTC medication resources

• First Nations Health Benefits (Plan W) OTC Drugs
• HLTH 4571 - Plan W OTC Recommendation form (PDF, 548KB)
• HLTH 5840 - MACS Form (PDF, 705KB)

Insulin products & non-drug items

Insulin products

Insulin products are excluded from this policy. Insulins can be dispensed and entered in PharmaNet without a prescription or a Plan W OTC Recommendation form. Refer to Section 5.14—Insulin.

Non-drug OTC items

PharmaCare covers specific non-drug items under Plan W at their retail price up to a maximum set by FNHA, with no dispensing fee. Refer to Section 5.9—Retail Pricing Policy.

Claims for these items automatically adjudicate under Plan W and can be dispensed to a client with or without a prescription from a prescriber.

Please refer to First Nations Health Benefits (Plan W) Non-Drug OTC PINs.

Medical supplies and equipment

Additional medical supplies and equipment (MS&E) for FNHA clients are covered by FNHA through Pacific Blue Cross (PBC).

• Refer to the FNHA Medical Supplies & Equipment Benefit page for more information, and to find a list of eligible items

Out-of-province benefits

Out-of-province purchases of Plan W benefits may be reimbursed if the client submits an HLTH 5480 - Out-of-Province claim (PDF, 656KB) 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 PharmaCare Help Desk. The Help Desk will attempt to confirm active Plan W coverage and update PharmaNet. 
2. Once the Help Desk confirms that short-term assistance is in place, process the prescription as usual.

If the client has a prescription for an OTC drug

1. Enter the claim in PharmaNet as you would any other prescription.
2. Retain a copy of the prescription on file.

If pharmacist recommends treatment with an OTC eligible for Plan W coverage

1. Complete the HLTH 4571 - Plan W OTC Recommendation form (PDF, 932KB) or another form that captures the same information.
2. Enter the claim with P1 (for College of Pharmacists of BC) in the PRACT ID REF field and the College Registration Identification (Reg ID) of the recommending pharmacist in the Prescriber ID field.
3. Retain a record of the purchase similar to that required for prescription items.

If an eligible OTC is recommended as a result of the Minor Ailments and Contraception Service (MACS)

1. Document the recommended OTC on the MACS Form (PDF, 705KB) or another form that captures the same information.
2. Enter the claim with P1 (for College of Pharmacists of BC) in the PRACT ID REF field and the College Registration Identification (Reg ID) of the recommending pharmacist in the Prescriber ID field.
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, pharmacies can contact the PharmaCare Help Desk, and clients should contact HIBC.