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Author: Admin | 2025-04-28
Opioids, benzodiazepines, gabapentin, pregabalin, stimulants and nabilone are prescribed to be dispensed for a longer duration as a single prescription, NIHB will reimburse up to a maximum of 30 days at a time. For claim verification purposes, prescriber approval to split a prescription into 30-day dispenses will not be required for these medications. Please be advised that the claims processor is unable to automatically reduce the day supply to 30 days. Providers are expected to manually apply the policy. The 30-day maximum dispense policy does not apply to claims submitted according to the NIHB Opioid Use Disorder Treatment Policy. For more information, please refer to section 2.13.4 Opioid use disorder treatment. 2.13.3 Drug Utilization Review program A Drug Utilization Review (DUR) program, which is part of the point of sale or online adjudication system, provides an analysis of both previous claims data and current claims data to ensure that providers are advised of potential drug-related problems or interactions. Messages are returned to pharmacists to alert them of potential problematic drug use, such as potential drug interactions, duplicate drugs and therapies, and early refills. The DUR has special warning messages for the misuse of specific drugs of concern, including opioids, benzodiazepines and methadone. For more information, please refer to the Pharmacy Claims Submission Kit available on the Express Scripts Canada NIHB provider and client website. 2.13.4 Opioid use disorder treatment 2.13.4.1 Methadone NIHB compensates compounded methadone (pseudo-DIN 00908835) or commercially available methadone solution (for example, Methadose, Metadol and their generics for the treatment of opioid use disorder). The NIHB program has specific requirements for drug cost, mark-up and dispensing fees when billing methadone for the treatment of opioid use disorder. These apply to both witnessed and carried doses. Effective October 16, 2024, the dispensing fee for methadone is based upon the following formula for each day of methadone treatment: (Dispensing Fee/7) + $6.18. For claims filled on the same day, the electronic claim adjudication system will allow a single transaction up to a maximum 14-day supply or more than 1 transaction for a combination of up to a maximum 14-day supply.
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