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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 Retiree Benefits Rate Sheet. See the Enrolling section for information on How to Make a Change to your current Health and/or Dental Option during the annual re-enrolment window in early March.

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.

Option 1 Option 2 Option 3 Option 4
Prescription drugs
(mandatory generic substitution)
 80% reimbursement of the first $150 per eligible drug expense, and 100% thereafter You pay an annual* deductible before drug coverage begins ($300 single/$600 family**); 80% of the first $150 per eligible drug expense, and 100% thereafter
  • April 1 - March 31
  • $600 family refers to $300 for yourself and another $300 for all of your eligible dependents combined
 You pay the first $50 per eligible drug expense, and 100% thereafter Coverage for vaccines only: 80%, to a $500 lifetime maximum per person
Hospital accommodations No private or semi-private coverage 100% reimbursement of the difference between a ward and semi-private room
80% between semi-private and private
Paramedical practitioners 80% reimbursement to specified annual maximums
Vision care 80% reimbursement to specified annual maximums
Medical services 80% reimbursement to specified annual maximums
Medical equipment and supplies 80% reimbursement to specified annual maximums

Supplement your health benefits by taking steps towards improving your diet. Good nutrition is an important part of leading a healthy lifestyle. Check out Canada's Food Guide to learn how to easily incorporate a balanced diet into your daily life.

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

Option 1 Option 2 Option 3 Option 4
80% of the first $150 per eligible drug expense, and 100% thereafter You pay an annual deductible before drug coverage begins ($300 single/$600 family)
80% of the first $150 per eligible drug expense, and 100% thereafter
 You pay the first $50 per eligible drug expense, and 100% thereafter Coverage for vaccines only: 80%, to a $500 lifetime maximum per person
Reimbursement is based on your prescription drug coverage option:
  • $500 lifetime maximum for preventative vaccines and toxoids
  • 50% reimbursement of the usual cost of nicotine replacement products, subject to a lifetime maximum of $300 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, unless your doctor provides medical evidence that the prescribed drug cannot be substituted.

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.

Option 1

You will not pay more than $30 per eligible drug appearing on your prescription if you select the lowest-cost generic drug or a brand name drug without a generic equivalent.

  Example 1 Example 2
  $50 Prescription Cost
(lowest-cost generic)
 $200 Prescription Cost
(lowest-cost generic)
The plan pays 80% of $50 = $40 80% of the first $150 = $120
100% of the remaining $50 = $50
$120 + $50 = $170
You pay 20% of $50 = $10 20% of $150 = $30

Option 2

Each policy year (April 1 to March 31), you pay the first $300 (single coverage) or $600 (family coverage) of eligible prescription drug expenses before the plan begins to cover drug expense.

After you have met your deductible, you will not pay more than $30 per eligible drug appearing on your prescription if you select the lowest-cost generic drug or a brand name drug without a generic equivalent.

  Example 1 Example 2
  $50 Prescription Cost
(lowest-cost generic)
 $200 Prescription Cost
(lowest-cost generic)
Annual deductible $300 single
$600 family
 $300 single
$600 family
The plan pays 80% of $50 = $40 80% of the first $150 = $120
100% of the remaining $50 = $50
$120 + $50 = $170
You pay 20% of $50 = $10 20% of $150 = $30

Option 3

You will not pay more than $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.

  Example 1 Example 2
  $50 Prescription Cost
(lowest-cost generic)
 $200 Prescription Cost
(lowest-cost generic)
You pay $50 of the first $50 $50 of the first $50
The plan pays $50 - $50 = 0 $200 - $50 = $150

Option 4

No coverage for drugs, except for vaccines.

 

Note About the Seniors’ Drug Cost Assistance Program (DCAP)

The PSGIP covers non-DCAP drugs. If you are participating in the government’s Seniors’ DCAP and you purchase a prescription under DCAP, you will have to pay $8.25 plus $7.69 of the pharmacy professional fee per drug.

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
  • Products used to quit smoking, except nicotine replacement products
  • Spring-loaded devices used to hold lancets
  • Sunscreens
  • Vitamins (except injectible), minerals, dietary supplements

Hospital Accommodations

Under Option 4 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, and
  • 80% of the difference in cost between a semi-private and 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 (regardless of option) 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 (regardless of option) 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:

  • Chiropodists or podiatrists
  • Chiropractors
  • Massage therapists
  • Occupational therapists
  • Osteopaths
  • Registered physiotherapists
  • Laboratory tests and X-rays are covered if they are recommended by one of the covered licensed practitioners

Vision Care

The plan covers the usual cost of eligible vision care as follows (general exclusions apply):

Eye exams
(including eye refractions)
  • 80% reimbursement
  • For persons over age 18: once every 2 calendar years
  • For children age 18 and under: once every calendar year

A registered, licensed optometrist or ophthalmologist must perform the eye exam.
Eye glasses or contact lenses
  • 80% reimbursement, to a maximum of $80 every 2 calendar years (every calendar year 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 $160 in any period of 2 calendar years

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% of the first $50 of eligible expenses per calendar year, and 80% thereafter.

Can be reimbursed up to $240 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 $8,000 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

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 $40 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

Breathing appliances

Reimbursed up to $240 every 5 calendar years

Examples of breathing appliances: respirators, compressors, and inhalers (including Maxi-Mist, Medi-Mist, Shucho Mist, and Pulmo Aids)

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.

Insulin pumps

Covered once every 5 years, to a maximum reimbursement of $5,200

Ostomy supplies

Covered if approved by Canada Life

To determine the eligible reimbursement amount, submit a pre-approval to Canada Life.

Oxygen

  

Raised toilet seat

  

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 2 pairs each calendar year

Surgical/mastectomy bras

2 per 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.

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 $40 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.

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
  • TENS units
  • Transfer bench
  • Trapeze
  • Wigs

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), except for temporomandibular joint dysfunction appliances