Covered Health Care Expenses

This insurance applies to expenses you are required to pay for the treatment of pregnancies and Non-Occupational accidents and sicknesses.  The charges will only be considered eligible expenses provided the charges are reasonable and customary.  The supplies or services must be medically necessary and prescribed by a Physician, or other qualified medical practitioner deemed appropriate by the insurance carrier. A medical expense shall be deemed incurred as of the date the service or supply is furnished to you, and you must be covered on that date for the expense to be considered.  The insurance will pay the following covered expenses incurred by you or an eligible Dependent up to the limits described below and set out in the "SUMMARY OF BENEFITS".
 
Drugs and medicines including injectibles which are medically necessary, legally require a written prescription from a Physician in order to be purchased, and are dispensed by a licensed pharmacist, or Physician legally authorized to dispense such drugs, plus drugs that regardless of their legal status are not normally sold except by prescription. These drugs must be prescriptive, restrictive, controlled or narcotic in nature. Included are diabetic supplies, and oral contraceptives.  Also included are substances used for injections, except when required for recreational or lifestyle reasons, such as non-work related travel.  In an effort to contain costs, it is requested that generic drug substitutes be used whenever possible.

The maximum single purchase of drugs that will be considered is the amount that can reasonably be used within 90 days of the date of purchase.

Active Members aged 65 and over will continue to be eligible for the same level of drug coverage as those active Members under age 65. These Members are required to claim through the Ontario Drug Benefit (ODB) first. The Trust Fund will cover the deductible and any drugs eligible under the plan that is not included in the ODB formulary.

Not eligible for reimbursement:  Any drug not approved by the Food and Drugs Act, Canada.  Proprietary or patent medicines (off-the-shelf preparations), dietary or health food, erectile dysfunction drugs, fertility drugs, unless prescribed for other than fertility purposes, nutritional products and charges for the administration of drugs, whether or not a prescription is given for medical reasons. 
 
Note: The Trustees reserve the right to modify the drug formularies and definition at any time in the future, in order to deliver the benefit in a contemporary fashion.

Prescription Drug Card: On January 1, 2013, the Reimbursement Drug Benefit was replaced by the Prescription Drug Card Benefit. When you drop off a prescription, present your Prescription Drug Card to the pharmacist.”
 
Ambulance service charges, including emergency air ambulance service, in excess of the amount payable under the insured person’s Provincial Health Plan and to the limits specified by this plan’s “SUMMARY OF BENEFITS”.   The services must be required to transport the person from the place of injury (or where illness struck) to the nearest Hospital where treatment is available, or directly from that Hospital to the nearest Hospital for needed specialized treatment not available at the first Hospital, or from Hospital to a Convalescent/Rehabilitation Hospital. 

Out of Hospital Nursing services of a Registered Nurse (R.N.), while the patient is not confined to a Hospital, and up to the limit specified in the “SUMMARY OF BENEFITS”.  The nursing service must have been ordered by a Physician as medically necessary and requiring the specialized training of a registered nurse.  The nurse must not ordinarily reside in the Member's home or be a Member of the family.  Charges for services that are mainly custodial or assist the individual with the functions of daily living are not covered.  Coverage is subject to obtaining pre-approval.

Health Practitioner Benefits charges up to the amounts specified in the “SUMMARY OF BENEFITS” for a properly accredited Chiropractor, Naturopath, Osteopath, Acupuncturist, Dieticians, Nutritionists and Chiropodist/Podiatrist. Licensed Clinical Psychologist/Psychotherapist/Social Worker, Registered Massage Therapist and Speech Therapist, must be acting within the scope of their licences. Massage Therapy must be prescribed by a Physician as to diagnosis and medical necessity. Where applicable, X-rays are covered. No amount will be paid for any Health Care Practitioner services until any applicable Provincial Health Plan benefit is exhausted.

Physiotherapy charges up to the amounts specified in this Plan’s “SUMMARY OF BENEFITS”, by a physiotherapist who is registered and legally practicing within the scope of his license.  No amounts will be payable for any visits for which any amount is payable under the insured person’s Provincial Health Plan, unless permitted by law.

Dental Care for Accidental Injury charges up to the amounts specified in the Plan’s “SUMMARY OF BENEFITS”, for necessary dental care by a licensed dentist for the prompt repair of sound natural teeth when required for a Non-Occupational accidental injury, external to the mouth, which occurs while insured.  The dental work must be completed within 12 months of the accident to be a covered medical expense.
Diagnostic Laboratory and X-Ray Expenses not covered by any provincial health plan.

Durable Medical Equipment and Supplies - Charges for the rental of or, at the option of the Insurer, the purchase of durable medical equipment of the type and model adequate for the insured person’s medical needs based on the nature and severity of the disability, such as but not limited to:

1. Hospital beds, wheelchairs, canes, crutches, walkers and trusses;
2. Rigid or semi-rigid braces for back, neck, arm or leg and non-dental prosthesis, such as artificial limbs and eyes, a surgical corset, including replacement if required because of a change in physical condition;
3. Respiratory equipment, including oxygen;
4. Splints, casts, and catheters;
5. Breast prosthesis – refer to limits in “SUMMARY OF BENEFITS”;
6. Purchase of surgical brassieres when required following a mastectomy – refer to limits in “SUMMARY OF BENEFITS”;
7. Surgical stockings, excluding elastic stockings – refer to limits in “SUMMARY OF BENEFITS”;
8. Wigs – refer to limits in “SUMMARY OF BENEFITS”; and
9. Glucometer to the limits in “SUMMARY OF BENEFITS”.

Not eligible are items of personal comfort, convenience, exercise, safety, self-help or environmental control items, or items which may also be used for non-medical reasons, such as, but not limited to heating pads or lamps, communication aids, air conditioners or cleaners, and whirlpool baths or saunas.

Before incurring any major expenses you are encouraged to submit details to the Claims Office to determine to what extent benefits are payable. In any event, a letter will be required from a licensed Physician describing the nature of the disability and the type, medical need and estimated duration of any required durable medical equipment. 

Note: The Ontario Assistive Devices Program may provide partial reimbursement for certain expenses listed above, e.g. prosthetic devices, respiratory equipment, hearing aids, wheelchairs, Hospital beds, etc. Further information regarding this program may be obtained by calling 1-800-268-6021.
 
Foot Care benefits are subject to the limits specified in the “SUMMARY OF BENEFITS”.   Charges for orthopedic shoes (including repairs) and orthotics which have been specially designed and molded for the insured individual and are required to correct a diagnosed physical impairment, provided that the following information is supplied:

1. a diagnosis, including list of symptoms and the primary complaint;
2. a description of the physical findings from the clinical examination;
3. a brief description of the gait abnormality associated with the diagnosis; and
4. confirmation that the product has been custom-made.

In order to be eligible for reimbursement, orthopedic shoes and orthotic devices must be prescribed, on an annual basis, by either a licensed Physician or Chiropodist/Podiatrist, and must be dispensed by one of the following provider types: licensed Physician, Chiropodist/Podiatrist, Orthotist, or Pedorthist.

Please note: Orthopedic Shoes and Orthotics provided by Chiropractors are excluded from this group

Hearing Aid charges, excluding replacement, repair, or batteries, when provided by a certified, clinical audiologist, up to the amount specified in the “SUMMARY OF BENEFITS”.