Overview
Illness or injury can strike when you least expect it. When it does, you should be able to focus on getting better, not on how to pay your bills. That’s why the plan offers you and your family health care coverage. It is designed to complement the provincial plan and help pay major health expenses.
For a summary of your health coverage, refer to the Benefits At-a-Glance section. There you will find information on reimbursement levels and applicable maximums. You can also find information about the current rates in the Benefits Rate Sheet.
Eligible expenses must be reasonable and customary, medically necessary and incurred while the individual was covered under the plan.
Payment will be based on reasonable and customary charges in the area in which the treatment is given as determined by the insurer adjudicating benefits. Limits may apply to specific services and supplies.
For a list of health plan exclusions, see the Exclusions section.
| Prescription drugs
(mandatory generic substitution) |
100% reimbursement, after you pay the first $7.50 per eligible drug expense |
| Hospital accommodations |
100% reimbursement of the difference between a ward and semi-private room |
| Paramedical practitioners |
100% reimbursement to specified annual maximums |
| Vision care |
100% reimbursement to specified annual maximums |
| Medical services |
100% reimbursement to specified annual maximums |
| Medical equipment and supplies |
100% reimbursement to specified annual maximums |
Prescription Drugs
Coverage is based on the lowest-cost generic equivalent of the prescribed brand name drug, unless your doctor provides medical evidence that the prescribed drug cannot be substituted.
Eligible drugs must be approved by the Canadian government for sale to the general public and have a Drug Identification Number (DIN). However, the plan may cover the usual cost of certain life-supporting, non-prescription drugs approved by Canada Life.
Prescription drugs can be prescribed by any of the following medical practitioners:
Coverage
- 100%, after you pay the first $7.50 per eligible drug expense
- $500 lifetime maximum for preventative vaccines and toxoids
- 50% reimbursement of the usual cost of nicotine replacement products, subject to a lifetime maximum of $100 per person
- $250 maximum per calendar year for sexual dysfunction medications
- 100-day supply for therapeutic or maintenance drugs
Certain general exclusions also apply.
Remember to use your pay-direct drug card when filling a prescription to get your claim processed on the spot. You then only need to pay out-of-pocket what’s not covered by the plan.
How Your Reimbursement Works
The plan will cover the usual cost of the lowest-cost generic drugs requiring a prescription. You will not pay more than $7.50 per eligible drug appearing on your prescription if you select the lowest-cost generic drug or a brand name drug without a generic equivalent.
You can select a brand name drug that has a generic equivalent, but you may pay more if there is no medical reason for choosing the brand name drug over the generic substitution.
Example:
Here’s an example of how prescription drug costs are reimbursed.
| |
$50 Prescription Cost
(lowest-cost generic) |
| You pay |
$7.50 |
| The plan pays |
100% of $42.50
($50 - $7.50) |
What is a Generic Drug?
Generic drugs are like brand name drugs in dose, strength, and how they are taken. They have the same active ingredients and are equally safe and effective. The only difference in composition is their inactive ingredients - the binders, fillers, and dyes used to give the drugs their shape and colour. These differences have no effect on the drugs’ active ingredients or how it works.
Generic drugs are less expensive than brand name drugs because the generic drug manufacturers do not have to recoup research and development costs incurred by brand name manufacturers after the patent protection expires. As result, these savings can be passed on to consumers and group benefit plans.
By law these generic drugs are considered interchangeable with brand name drugs and pharmacists are allowed to substitute for the generic option when you have a prescription filled. Generic drugs are regulated by Health Canada and undergo constant testing to ensure they meet strict requirements.
What if the Lowest-Cost Generic Equivalent Doesn’t Work for Me?
If there is a medical reason why you cannot take the generic equivalent of the brand name drug, you can still request that the brand name drug be covered by the plan. You and your doctor must complete Canada Life’s Request for Brand Name Drug Coverage form.
Send the completed form to Canada Life at the address indicated on the form. Canada Life will assess your request and send you a letter letting you know if the request for brand name drug coverage is approved.
Pay-Direct Drug Card
For your convenience, the plan provides you with a pay-direct drug card, which you can use to pay for prescription drugs, diabetic supplies, and certain over-the-counter, life-supporting drugs that have been prescribed for you and approved for reimbursement by Canada Life.
Claims are processed immediately, so you only have to pay your co-pay amount. That means you have no claims to submit and you won’t be waiting for reimbursement.
What the Plan Does Not Cover
- Alcohol
- Bandages
- Blood glucose monitors, dextrometers
- Contraceptives other than contraceptive drugs and products containing a contraceptive drug
- Cosmetic items
- Cotton
- Disinfectants
- Fertility drugs
|
- Food substitutes, infant food or formula
- Hair growth stimulants
- Homeopathic medicines
- Non-disposable insulin injectors
- Products that can be bought without a prescription, unless the policyholder approves them
- Spring-loaded devices used to hold lancets
- Sunscreens
- Vitamins (except injectible), minerals, dietary supplements
|
Hospital Accommodations
The plan covers the usual cost of hospital accommodation in Canada:
- 100% of the difference in cost between a ward and a semi-private room.
If you are medically required to be admitted into a private room, the provincial plan will cover the cost at 100%.
The plan also pays 100%, up to $1,000 per hospital admission, of the usual cost of medically necessary ancillary hospital services if you are admitted as an inpatient to a general hospital in another province and a government health plan does not fully cover the cost. Ancillary hospital services include items such as drugs or recovery room expenses that were not picked up by the provincial plan.
If you are an out-patient, the plan pays the usual cost of out-patient services and supplies from a hospital or a surgical supply company.
Paramedical Practitioners
The plan covers the usual cost of paramedical services, provided your paramedical practitioner is registered in the province where the service is given. The practitioner cannot be a member of your immediate family or someone who lives with you.
The following list of practitioners are covered under the plan, up to the limits specified in the Benefits At-a-Glance section:
- Acupuncturists
- Chiropodists* or podiatrists*
- Chiropractors*
- Massage therapists
- Naturopaths
- Occupational therapists
- Osteopaths*
- Physiotherapists
- Psychologists or social workers
- Speech therapists
Vision Care
The plan covers the usual cost of eligible vision care as follows (general exclusions apply):
| Eye exams
(including eye refractions) |
- 100% reimbursement
- For persons over age 18: once every 24 consecutive months
- For children age 18 and under: once every 12 consecutive months
A registered, licensed optometrist or ophthalmologist must perform the eye exam. |
| Macular degeneration tests |
A registered, licensed optometrist or ophthalmologist must perform the test. |
| Eye glasses or contact lenses |
- 100% reimbursement, to a maximum of $250 every 24 consecutive months (every 12 consecutive months for children age 18 and under)
- Includes coverage for prescription sunglasses and safety glasses
An ophthalmologist or optometrist must prescribe the contact lenses or eye glasses to correct vision. |
| Contact lenses for certain conditions |
- If you suffer from ulcerated keratitis, severe corneal scarring, keratoconus (conical cornea) or aphakia: reimbursed up to $200 in any period of 24 consecutive months
A licensed ophthalmologist must prescribe the contact lenses. The plan will pay for these contact lenses only if your sight can be improved to at least the 20/40 level by contact lenses, but it cannot be improved to that level with eye glasses. |
Medical Services
The plan covers the usual cost of eligible medical services as follows (general exclusions apply):
| Eligible Expenses |
Special Notes |
Accidental dental treatment |
The plan covers the usual cost of repairing or replacing any healthy, natural teeth that have been damaged or lost due to a sudden impact.
To be reimbursed, you must complete treatment within 12 months of the impact, unless treatment has to be postponed because of your age.
Reimbursement will be based on the least expensive treatment that is adequate to correct the damage and on the current dental fee guide. No implants, treatments related to implants, or treatments to correct existing problems are covered by this part of the plan. |
Ambulance services |
If you are in an accident or become critically ill, the plan will cover the usual cost of a licensed ambulance or other emergency service to transport you to the nearest hospital that is able to give the necessary emergency treatment. This also covers travel between hospitals.
Reimbursed at 100%.
Can be reimbursed up to $300 in any calendar year for the travel expenses of an accompanying registered nurse, when medically necessary and approved by the plan. The nurse cannot be a relative.
If a licensed ambulance does not provide transportation for someone to accompany you, the plan may cover the cost of a person to accompany you, if it is medically necessary. |
Private-duty nursing |
The plan will cover the usual cost of private nursing care at your home or in the hospital, up to $5,000 per covered person each calendar year, provided all of the following conditions are met:
- your doctor has determined, in writing, that it is medically necessary,
- Canada Life has approved the service beforehand,
- nursing care is provided within Canada by a registered nurse, registered nursing assistant, or registered practical nurse,
- the person providing nursing care does not normally live with you or is not a member of your immediate family,
- if nursing care is provided in a hospital, the person is not an employee of the hospital,
- the nursing care professional provides skilled care that only they can provide, and
- the nursing care is not provided in a nursing home, rest home, home for the aged, or any facility that provides similar care.
|
Medical Equipment and Supplies
The plan covers the usual cost of eligible medical equipment and supplies as follows (general exclusions apply):
| Eligible Expenses |
Special Notes |
Aerochambers |
Covered if approved by Canada Life |
Apnea monitor |
Covered if approved by Canada Life
To determine the eligible reimbursement amount, submit a pre-approval to Canada Life. |
Artificial limbs/eyes and other prosthetic devices |
Covered if non-myoelectric and approved by Canada Life
Important notes:
- Talk to Canada Life before making your purchase, as the cost varies greatly. Canada Life will let you know how much the plan will pay based on the least expensive device that is medically adequate.
- Replacements are covered if they are due to a pathological change.
- The plan pays for repairs and/or adjustments up to $50 in any calendar year, including the cost of repairs and/or adjustments to walkers and braces.
|
Asthma nebulizer |
Covered if approved by Canada Life
To determine the eligible reimbursement amount, submit a pre-approval to Canada Life. |
Breast prosthesis after mastectomy |
Including replacement(s) every 2 calendar years |
Casts |
Covered if approved by Canada Life
To determine the eligible reimbursement amount, submit a pre-approval to Canada Life. |
Certain diagnostic tests, radium treatments, and X-rays |
|
Compressors |
Covered if approved by Canada Life
To determine the eligible reimbursement amount, submit a pre-approval to Canada Life. |
Crutches and canes |
|
Custom-made foot orthotics |
Expenses are reimbursed up to $240 per calendar year (including custom-made orthopedic shoes and any modifications)
- Must be prescribed by a physician, podiatrist or chiropodist as being necessary after a biomechanical examination, and
- Must be required for regular daily living activities, and not just for sports or recreation.
|
Custom-made orthopedic shoes, including modifications |
Expenses are reimbursed up to $240 per calendar year (including custom-made foot orthotics)
- Must be prescribed by a physician, podiatrist or chiropodist, and
- No other method, such as orthotics and/or off-the-shelf orthopedic shoes, can correct the problem.
|
Diabetic supplies |
You can use your drug card to cover these expenses
Examples of diabetic supplies: disposable needles, syringes, lancets and testing materials for monitoring diabetes |
Hearing aids and repairs |
Reimbursed up to $900 per ear every 5 calendar years
Batteries are not covered. |
Hospital beds |
Reimbursement based on:
- the cost of rental or purchase, whichever is more economical,
- Canada Life’s approval before the purchase is made, and
- the least expensive device that is medically adequate.
Spare parts or alternative supplies are not covered. |
Mastectomy Bras |
Up to 2 per calendar year
|
Ostomy supplies |
Covered if approved by Canada Life
To determine the eligible reimbursement amount, submit a pre-approval to Canada Life. |
Oxygen |
|
Oxygen equipment |
Covered if approved by Canada Life
To determine the eligible reimbursement amount, submit a pre-approval to Canada Life. |
Stump socks |
|
| Surgical stockings |
Up to 4 pairs each calendar year |
Temporary therapeutic equipment |
Reimbursement based on:
- the cost of rental or purchase, whichever is more economical,
- Canada Life’s approval before the purchase is made, and
- the least expensive device that is medically adequate.
Spare parts or alternative supplies are not covered. |
TENS machines |
Transcutaneous electrical nerve stimulation (TENS) machines are covered if used to treat a chronic condition.
100% reimbursement, limited to 1 TENS machine every 5 years, to a maximum of $500 per covered person and a $700 lifetime maximum per covered person.
Important note
To process your claim, Canada Life must receive:
- name of supplier (including receipt)
- physician’s prescription that must include:
- referral for TENS machine
- nature of the condition being treated
- confirmation of the chronic nature of the condition
|
Walkers and braces |
Covered if approved by Canada Life
Important notes:
- Talk to Canada Life before making your purchase, as the cost varies greatly. Canada Life will let you know how much the plan will pay based on the least expensive device that is medically adequate.
- Replacements are covered if they are due to a pathological change.
- The plan pays for repairs and/or adjustments up to $50 in any calendar year, including the cost of repairs and/or adjustments to standard non-myoelectric artificial limbs/eyes and other approved prosthetic devices.
|
Wheelchairs
(standard manual or electric) |
Reimbursement based on:
- the cost of rental or purchase, whichever is more economical,
- Canada Life’s approval before the purchase is made, and
- the least expensive device that is medically adequate.
Spare parts or alternative supplies are not covered.
If the purchase is approved, the plan limits the coverage of the rental or purchase of other similar equipment to once every 5 calendar years. |
Wigs |
Reimbursed up to $250 lifetime maximum
|
What the Plan Does Not Cover
The plan does not cover the following items or any other item not listed as an eligible expense, even when prescribed by a physician:
- Air conditioners or purifiers
- Blood pressure kits
- Breast pumps
- Cataract contact lenses
- Craftmatic, Ultramatic, or other lifestyle beds
- Exercise equipment, machines, or programs
|
- Grab bars
- Holter monitor
- Home or car modifications (for example, ramps or lifts)
- Hoyer lift
- Humidifiers
- Mattresses, except for standard mattresses with approved hospital beds
- Obus formes or orthopaedic pillows
|
- Raised toilet seats
- Transfer bench
- Trapeze
|
Exclusions
The following list of exclusions applies to the health and travel plans.
- Any service for which reimbursement is prevented by law
- Cosmetic treatments
- Health care services or supplies required as a result of any of the following:
- committing a criminal offense or provoking an assault
- intentionally self-inflicted injury
- participation in a riot or civil disturbance
- war, rebellion, or hostilities of any kind, whether you are a participant or not
- Health care services or supplies required solely for recreation or sports purposes
- Health care services or supplies that you are eligible to claim under any workers’ compensation legislation in your province of residence
- “In vitro” or “in vivo” procedures, or any other infertility procedures, unless otherwise specifically covered in this plan
- Services or supplies for which you would normally not be charged
- Services required by a court, your employer, a school, or anyone other than your physician (for example, if your employer requires a doctor’s note or a court requires that you receive psychological treatment)
- Treatment to correct temporomandibular joint dysfunction (joint of the jaw)
