What the non-opioid request is for
The form covers any non-opioid medication that isn’t covered on the worker’s formulary, and doses above a drug’s quantity limit. WCB’s guidance gives an example: a worker with compensable asthma who needs a combination inhaler must show they’re on optimal inhaled corticosteroids, still have symptoms, and need more short-acting bronchodilator. Brand-name drugs where a generic exists go on the Mandatory Generic Exemption Request, and medical cannabis has its own initial and extension forms.
Who completes it
The prescriber completes and signs it. There’s no worker section.
How to fill in the request
Worker and injury information
Enter the claim number, the worker’s name, date of birth, address and health card number, and the diagnosis. Workers can have more than one claim, and each has its own formulary, so check the claim number matches the injury you’re treating.
Treatment plan
Give the product name and strength, directions, start date and expected duration. For an original request, explain the expected benefit to recovery from the compensable injury and tick the reason a covered drug won’t do: contraindication, adverse event, therapeutic failure or other. For a renewal, describe the clinical effectiveness and functional improvement so far.
Medications and therapies tried
List each medication tried for this condition with dosage, duration, outcome and whether it’s ongoing. This section is mandatory. Then list the non-drug therapies tried. Medavie Blue Cross reviews against the drug’s criteria, so name the drugs that failed and why.
Prescriber information
Add your name, address, phone, fax and licence number, then sign and date. The signature is mandatory.
Common reasons it’s delayed or refused
- An opioid requested on this form.
- The medications tried section left blank.
- A renewal with no evidence of benefit.
- The wrong claim number for the injury being treated.
- A request for a brand-name drug that belongs on the generic exemption form.
Submitting and who pays
Fax the request to Medavie Blue Cross at (902) 496-5819 or mail it to PO Box 2200, Halifax, NS B3J 3C6. Physicians bill the form under MSI fee code WCB23, and other prescribers invoice WCB directly. If the criteria are met, Medavie Blue Cross sends you a letter with the coverage terms, and the worker is told the medication will be covered at the pharmacy.