Plan W – information for health professionals

The First Nations Health Authority (FNHA) was created in 2013 to transform how healthcare is delivered to First Nations people living in B.C. At that time, FNHA assumed responsibility for programs and services previously delivered by Health Canada. The FNHA serves over 200 diverse First Nations communities and their members.

In 2017, the FNHA and PharmaCare collaborated to create Plan W; the project transitioned the administration of pharmacy benefits from federal programs to a First Nations–owned PharmaCare plan: Plan W. The W stands for Wellness.

The unique governance structure of FNHA and the partnership with PharmaCare enabled Plan W to be designed to meet the unique needs of First Nations people in B.C., allowing for the deconstruction of distinct, race-based benefits pathways.

Cultural safety and humility 

PharmaCare counts on healthcare professionals to practise cultural humility and create an environment free of racism, as mandated by the Indigenous Cultural Safety, Cultural Humility and Anti-Racism Practice Standard (Health Professions Act – Bylaws, Schedule F, Part 7). This is a responsibility of each individual provider and includes providing covered medications, supplies, and pharmacy services as well as continuous learning and unlearning through reflection on how to interact with clients and uphold their best interests.    

To support their journey towards providing care that is considered safe, healthcare professionals can:

• Read Coming Together for Wellness (PDF, 894KB), a series of articles created by the FNHA in partnership with PharmaCare 

• Enrol in the San'yas Indigenous cultural safety training program

• Take UBC Pharm Sci's free, continuing education course for pharmacists, Cultivating Relationships and Creating Safer Spaces in Pharmacy for First Nations Clients 

• Visit the College of Pharmacists of BC’s Cultural Safety and Humility web page

PharmaCare coverage 

Plan W is the first payer of eligible pharmacy benefits, has no deductible, and covers 100 percent of the cost of eligible prescription medications, as well as select over-the-counter (OTC) drugs and non-drug items for FNHA clients.   

FNHA clients also access coverage for benefits and services through other programs: 

• Automatic PharmaCare coverage for additional drugs under Plan Z (Assurance) and pharmacy services (adaptations, vaccinations, minor ailment and contraception assessments, medication reviews, etc.)

• Other PharmaCare plans when they meet eligibility requirements

• Coverage for drugs granted through Special Authority (SA)

  • The FNHA transitional payment request process may be used to provide FNHA clients limited overage drugs at no cost when an SA request is pending and expected to be approved. This is based on a pharmacist's professional judgement, to support health care equity 

• PHSA’s specialized health care services (BC Cancer, BC Transplant, BC Renal, BCCfE and others) through the same mechanisms as other B.C. residents

• Additional health benefits through FNHA's partnership with Pacific Blue Cross

Confirming eligibility and supporting enrolment

First Nations individuals in B.C must be enrolled with FNHA to be covered by Plan W. To be eligible for FNHA enrolment, individuals must have Indian Status, live in B.C., and be enrolled in the Medical Services Plan (MSP).

Pharmacists and other healthcare providers are encouraged to ask First Nations individuals if they are enrolled with FNHA or have other means of coverage. Note that some First Nations individuals do not qualify for FNHA enrolment because they have coverage through self-government agreements.

In addition to FNHA enrolment, clients must have active MSP coverage to enrol in Plan W. It is very important that clients enrol in Plan W so they have the best available access to benefits. If a client may be eligible for Plan W and is currently not covered, pharmacists and other health providers should contact FNHA Health Benefits at 1-855-550-5454.

Through the transitional payment request, pharmacy providers are reimbursed for supporting clients with enrolment and providing medications at no cost to the client when the client is in the process of being enrolled with FNHA and does not have other means of coverage.  

Over-the-counter (OTC) medications 

Plan W OTC drug benefits are intended to support individuals in meeting their health and wellness goals. Products on the Plan W OTC drug list are eligible for 100% coverage under Plan W when the claims are entered into PharmaNet subsequent to: 

• A prescription from a practitioner (i.e., physician, nurse practitioner, midwife)  

• Completion of the Plan W OTC recommendation form (PDF, 548KB) when a pharmacist is recommending treatment

• Completion of the Minor Ailments and Contraception Service (MACS) form (PDF, 705KB) when a pharmacist is recommending an OTC item as part of a MACS (note the Plan W OTC recommendation form is not required when the OTC item is already documented on a MACS form) 

Supporting FNHA clients with accessing covered OTC drugs is considered a component of equitable and culturally safe pharmacy care. Should a pharmacist decide to not recommend and/or provide a covered OTC drug, they should discuss the therapeutic options available to the client and refer as appropriate.   

Eligible OTC drug claims should be fully covered, including the cost of a dispensing fee. In the event that an eligible, non-LCA or full-benefit LCA DIN is not 100 percent covered for an FNHA client, please call the PharmaCare Help Desk for a review of the price discrepancy. Pharmacy providers can then use the transitional payment request when a price discrepancy for a benefit OTC item prevents timely provision of a fully covered OTC drug.

Non-drug OTC items and medical supplies 

Specific non-drug OTC items are covered uniquely under Plan W at their retail price up to a maximum set by FNHA, with no dispensing fee. Pharmacies should not charge FNHA clients and instead enter claims into PharmaNet for the following: 

• Lancets 

• Blood and urine ketone strips 

• Alcohol wipes/pads 

• Inhaler spacers 

• Needles and syringes (not restricted to those for insulin injection) 

FNHA clients are also covered for the following medical supplies and equipment: 

• Blood glucose test strips (BGTS) – annual quantity limits apply. Providers can support FNHA clients newly diagnosed with diabetes by calling FNHA to activate coverage for the first fill of covered BGTS. For issues concerning coverage of BGTS for Plan W clients, contact the First Nations Health Benefits team at 1-855-550-5454

• Ostomy supplies for people who have undergone ostomy surgery and need an external pouch

Some supplies and equipment are covered only under specific circumstances. A Special Authority request must be approved for the following items to be fully covered under Plan W: 

• Insulin pumps for individuals who need insulin 

• Insulin pump supplies for individuals with an insulin pump 

• Continuous/flash glucose monitors for clients using intensive insulin therapy 

FNHA-Pacific Blue Cross Pharmacy Fee Supplement 

The FNHA has partnered with Pacific Blue Cross (PBC) to administer additional health benefits. The FNHA-PBC Pharmacy Fee Supplement lists a variety of drug and non-drug products to support unique FNHA wellness initiatives, including: 

• Shingles vaccine for people 60 years or older and available through exceptional request for people under 60 years 

• Infant formula 

• Nicotine replacement therapy coverage, in addition to what is covered under BC PharmaCare's Smoking Cessation Program (Plan S)

• Nasal naloxone 

• Select prescription drugs 

• Select medical supplies and equipment 

Supporting FNHA clients before and during out-of-province travel  

Plan W cannot automatically cover drug purchases made outside the province. B.C. pharmacists are expected to support clients with getting the full amount of medication covered under PharmaCare's Travel Supply Policy.  

If FNHA clients must purchase medication in another province, they can send an Out-of-Province Claim (PDF, 91.7KB) to PharmaCare with the original pharmacy receipt for it to be considered for reimbursement. Some pharmacies on the border, just outside, of B.C. are enrolled in BC PharmaCare and can submit a paper claim to PharmaCare on a client's behalf. 

Transitional payment request 

FNHA aims to support clients with access to continuity of ongoing therapy and immediate coverage of acutely needed items. The transitional payment request is a manual claim process for coverage of a one-time fill of an urgently needed product in cases of a coverage issue that is expected to be resolved soon, such as situations where a client's FNHA enrolment or Special Authority coverage request is pending.

The healthcare provider should provide the client with the product at no cost and bill FNHA using the FNHA Transitional Payment Request form (PDF, 201KB). The completed form, along with supporting documentation, should be faxed to FNHA at 1-888-299-9222.  

FNHA will reimburse pharmacists a $10 service fee for supporting the client in addition to the usual maximum drug cost and dispensing fee. The form can also be used to request transitional coverage for medical supplies and equipment that are urgent and eligible for coverage. The PIN 36420005 – TCR payment will show on the pharmacy payment statement from Pacific Blue Cross. 

If an FNHA client does not have Plan W as their primary drug plan, the pharmacist can support the client by submitting a transitional payment request with the client’s PHN, Status Number, DOB and contact information, indicating that the client requires Plan W enrolment. In this scenario, FNHA will reimburse pharmacists a $10 service fee. The PIN 36420006 – MSP enrolment payment will show on the pharmacy payment statement from Pacific Blue Cross. 

FNHA appeals process 

FNHA clients who have been denied coverage for an item or service have the right to appeal the decision up to 12 months afterwards. The FNHA’s appeals process considers the client’s unique circumstances, in addition to other available treatment options. Appeals can be submitted by the client, their parent or guardian, or a representative (including a pharmacist, with the client’s consent). For more information, visit FNHA Health Benefits Appeals.