Drugs
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, oral contraceptives and substances used for injections and inoculations. In an effort to contain costs, it is requested that generic drug substitutes be used whenever possible.
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, Nicorettes and similar anti-smoking related prescriptions when available over the counter, erectile dysfunction drugs, nutritional products and charges for the administration of drugs, whether or not a prescription is given for medical reasons.
However, Zyban, Champix and Fertility drugs are covered up to the limit specified in the “SUMMARY OF BENEFITS”
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.
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.
Pay Direct Drug Card
There is a Pay Direct Drug Card through Great West Life. This plan covers the cost of drugs which by law or convention require a Physician’s prescription including Smoking cessation aids which require a Physician’s prescription to the maximum set out in the “SUMMARY OF BENEFITS” and Fertility drugs to the maximum set out in the “SUMMARY OF BENEFITS.””
Ambulance
Ambulance service charges, including emergency air ambulance service within the continental limits of the United States and Canada, 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
Out of Hospital Nursing services of a Registered Nurse (R.N.), a certified/licensed Nursing Assistant (C.N.A., R.N.A., R.P.N., L.P.N. or L.N.A.), or a member of the Victorian Order of Nurses (V.O.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 employee'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, or for personal counseling are not covered. Coverage is subject to obtaining pre-approval.
Health Practitioner Benefits
Health Practitioner charges up to the amounts specified in the “SUMMARY OF BENEFITS” for a properly accredited Chiropractor, Occupational Therapist, Speech Therapist, Physiotherapist, Acupuncturist, Chiropodist/Podiatrist, Dieticians, Nutritionists and Registered Massage Therapist, acting within the scope of their licences. Also covered are charges for a Licensed Clinical Psychologist, Psychotherapist, and Social Worker. Where applicable, X-rays are covered. 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
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.
Diagnoistc Laboratory and X-Ray Expenses
Diagnostic Laboratory and X-Ray Expenses not covered by any provincial health plan.
Durable Medical Equipment and Supplies
Durable Medical Equipment and Supplies - Charges up to the limits specified in the “SUMMARY OF BENEFITS” for the rental of or, at the option of Manulife Financial, 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:
- Hospital beds, wheelchairs, canes, crutches, walkers and trusses;
- 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;
- Respiratory equipment, including oxygen;
- Contact lenses or glasses following cataract surgery (limited to one pair per lifetime);
- Splints, casts, catheters;
- Breast prosthesis – refer to limits in “SUMMARY OF BENEFITS”;
- Purchase of surgical brassieres when required following a mastectomy – refer to limits in “SUMMARY OF BENEFITS”;
- Surgical stockings, excluding elastic stockings – refer to limits in “SUMMARY OF BENEFITS”;
- Wigs – refer to limits in “SUMMARY OF BENEFITS”; and
- 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 the insured employee should submit details to the Administrator 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
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:
- a diagnosis, including list of symptoms and the primary complaint;
- a description of the physical findings from the clinical examination;
- a brief description of the gait abnormality associated with the diagnosis; and
- confirmation that the product has been custom-made.
- In order to be eligible for reimbursement, orthopedic shoes a
- nd orthotics 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.