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Depending on the treatment, the health care plan covers all or 80% of the cost of eligible health care expenses, subject to limits on certain benefits and a prescription drug dispensing fee cap. The expenses must be:

• Medically necessary (as determined by the insurance provider) for the treatment of illness or injury and, in most cases, prescribed by a licensed medical practitioner
• In the insurance provider's opinion, reasonable and customary expenses
• Not covered under the provincial plan or any other government-sponsored program
• Not in excess of any stated maximums
• Used as prescribed or recommended by a physician
• In the insurance provider's opinion due diligence for the drug, supply or service has been completed where required
• A medication that has been approved for use by Health Canada and assigned a drug identification number

New drugs, existing drugs with new indications, services and supplies are reviewed by the insurance carrier using their due diligence process. The insurance provider will decide to either i) include, ii) include with Prior Authorization criteria, iii) exclude or iv) apply maximum limits for the new or existing drug/services/supplies.

The insurance provider maintains a list of drugs, services and supplies that require prior authorization. Prior authorization is applied to ensure that the therapy prescribed is medically necessary. Where there are lower cost alternatives, you or your eligible dependents may be required to have tried an alternative treatment. To see the list of drugs requiring prior authorization, . The most up to date listing can be found under Forms - Plan Member Brochures.

At the insurance provider's discretion, medical information, test results or other documentation may be required to determine the eligibility of the drug, service or supply.

The insurance provider has the right to ensure you or your dependents access their exclusive distribution channels where applicable when purchasing a drug, service or supply.

The insurance provider may require you or your dependents to apply and participate in any patient assistance program(s) and reserves the right to reduce the amount of a covered expense by the amount of the financial assistance you or your covered dependents are entitled to receive under a patient assistance program.

In the event that a provincial plan or government-sponsored program or plan or legally mandated program excludes, discontinues or reduces payment for any services, treatments or supplies covered in full or in part by such plan or program, this plan will not automatically assume coverage of the charges for such treatments, services or supplies, but will reserve the right to determine, at the time of the change, whether the expenses will be eligible or not. We suggest that you check with the insurance provider before incurring large expenses.

There are various exclusions whereby the insurance provider will not pay benefits for expenses incurred for or in connection with such as, but not limited to:

• Care, services or supplies which are not medically necessary, as determined by the insurance provider
• Care, services or supplies which are for primarily cosmetic purposes, except those which are related to reconstructive surgery required to repair or replace damages by disease or bodily injury
• Care or services which are experimental or investigational – not approved as an effective, appropriate and essential treatment of an illness or injury
• Rest cures, travel for health reasons, periodic health checkups or examinations for the use of third party
• A medical condition caused by or related to war (whether or not war is declared), participation in any civil commotion, insurrection or riot, or while serving in the armed forces
• Services or supplies to the extent they are available under any government plan (benefits under a government plan must be accessed first before any benefits are payable)
• Additional, duplicate or replacement appliances or devices. (Note: subject to prior written approval by the insurance carrier, this exclusion will not apply if the replacement is required as a result of pathological change or because the existing item can no longer be made serviceable due to normal wear and tear)
• The services of a physiotherapist who has an agreement with the provincial health insurance plan
• Committing or attempting to commit, a criminal act
• Fees for completion of claim forms or other documentation, transfer of medical files or failing to keep a scheduled appointment
• Drugs, injectables, supplies or appliances which are experimental or are not approved by Health Canada
• Care, services or supplies used as treatment to a lifestyle choice (as determined by the insurance provider)
• Benefits or that part of benefits which cease to be payable under any government plan
• Drugs, medicines, services or supplies required for the condition requiring hospitalization while you or your dependents is an in-patient in a hospital
• Services or supplies that are covered under the Emergency Travel Assistance plan

Most eligible prescription drugs are covered at 80% when prescribed in writing by a physician or dentist and dispensed by a licensed pharmacist. The drug must legally require a prescription. This includes compounded preparations provided at least one of the ingredients is eligible.

The following apply:

• Overall maximum of $25,000/per calendar year, per covered person
• Maximum dispensing fee of $6.50
• Mandatory generic drug substitution
• Speciality drug plan and opioid management controls.

The plan covers 80% of the cost of services rendered by licensed practitioners to a combined annual maximum of $500 per covered person. A Physician’s written recommendation is not required for practitioner services.

Practitioners include:

• Massage Therapist
• Chiropractor
• Physiotherapist
• Psychologist, (includes Psychotherapist, MSW/Clinical Counsellor/Family Counsellor)
• Naturopath

The plan covers 80% of eligible expenses for:

• Semi-private hospital coverage in an Active Treatment Hospital or Chronic Care Hospital in excess of the Hospital’s standard ward accommodation charge

An eligible hospital must:

• Be licensed as a Hospital
• Have physicians and registered nurses on duty or on call 24 hours per day
• Be eligible to receive payments under a provincial hospital program

Confinement in an eligible hospital is covered regardless of the type of care being provided, such as rehabilitation, convalescent care, palliative care or drug and alcohol treatment.

Private hospitals that are not eligible to receive provincial funding are not eligible under the program.

Co-payment fees or similar charges for chronic care are not eligible for reimbursement.

Facilities not covered

• Federal hospitals
• Rest homes or homes for the aged
• Nursing homes/convalescent nursing homes
• Health spas or hotels

Exclusions: There may be further exclusions to this coverage. Please read the information on this page under "What's Not Covered".

The plan covers many medical services and supplies however; there are specific requirements and restrictions.  This website is not exhaustive and there may be additional items covered that are not outlined here.  Prior to incurring an expense, you are advised to submit a treatment plan and cost estimate to the insurance provider to determine eligibility and find out how much coverage you can expect. Reasonable and customary limitations apply and items must be deemed to be medically necessary by the insurance provider.

The plan covers 80% of the following expenses:

• Hearing aids limited to $500/ 5 years
• Orthotics/custom made orthopaedic shoes/adjustments to stock item shoes limited to $200 combined maximum per calendar year
• Wigs limited to a lifetime maximum of $400
• Other medical services and supplies (i.e. surgical stockings, brassieres, crutches, braces etc.)

The plan covers the following expenses:

• Diabetic supplies – glucometer, Continuous Glucose Monitoring (CGM), Freestyle Libre, etc. limited to reasonable and customary charges
• Insulin dependent diabetics subject to 3,000 strips per year
• Other diabetics subject to 400 strips/year