Section 9.0 To be considered reasonably necessary, the medical services or products must be ordered by a physician and must be commonly and customarily recognized throughout the physician's profession as
appropriate in the treatment of the patient's diagnosed sickness, injury or condition.
These plans will pay the excess over the deductible portion of the reasonable and customary charges and time limitations for the services and supplies set out in this brochure, when necessary for the care and treatment of injury or illness and when ordered or prescribed by a licensed medical practitioner.
The reasonable and customary charge of any service or supply is the usual charge of the provider for the service or supply, in the absence of the coverage, but not more than the prevailing charge in the area for a like service or supply. A like service is one of the same nature and duration, requires the same skill, and is performed by a provider of similar training and experience. “Area” means the municipality in which the service or supply is actually provided.
Reasonable and customary applies to all benefits. See pages 11 and 14 for some examples.
Section 10.0 The following medical services and supplies are not covered by the Extended Health Benefits Plan.
Services or supplies normally paid through any provincial hospital plan, any provincial medical plan, Workplace Safety & Insurance Board (WSIB), other government agencies or any other source.
Charges for unnecessary services and supplies for medical care of the patient's sickness, injury, or condition.
Coverage for the treatment of tuberculosis and mental illness when the patient is confined to a special institution for such treatment.
Rest cures, travel for health reasons or insurance examinations.
The portion of any charge, for any service or supply, in excess of the reasonable and customary charge.
For Benefits Items which may be eligible for coverage under the WSIB and/or the Assistive Devices Program, as well as The Company's Extended Health Benefits (EHB); employees can claim the difference between what they actually pay and the amount reimbursed by the government agency.
Example: A hearing aid costs $600.00
Assistive Devices Program
Great-West Life will reimburse $340.00
For services or supplies provided outside Ontario, the portion of any charge, or service, which exceeds the amount which would normally be paid in Ontario, will not be reimbursed.
The semi private differential between ward accommodation (covered by Ontario Health Insurance Plan (OHIP)) and semi private accommodation in an active treatment hospital, such as Toronto Hospital, is covered under this Plan. Also includes the Shouldice Clinic and the Homewood Sanitarium.
Up to $40.00 per day for a maximum of 120 days in any period of 365 consecutive days, towards semi private or private room accommodation in a hospital for the chronically ill or a chronic care unit of a general hospital.
The semi-private differential between ward accommodation (covered by the Ontario Health Insurance Plan (OHIP)) and semi-private accommodation in contract (private) hospitals, or in a convalescent/rehabilitative hospital, such as St. John’s in Toronto, up to a maximum of 120 days per lifetime.
Private Hospital Rooms: The Extended Health Benefits Plan covers the differential between semi private and private room accommodation (but not a suite) in an active treatment hospital.
The private room does not require a physician's authorization.
THE COMPANY’S DRUG PLAN
Drugslisted in The Company’s Drug Formulary are covered when purchased on the prescription of a licensed medical practitioner.
Employees are eligible for drugs for the current month, plus an additional two months, for a maximum of three months.
Pensioners are eligible for the current month, plus an additional seven months, for a maximum of eight months.
The following three conditions apply:
1. Maximum dispensing fee or drugs that "require a prescription by law" = $11.00 per prescription.
Where an employee is charged a "higher than normal dispensing fee" due to special handling or processing by the Pharmacist, the Assure Health Inc. (AHI) computerized billing will be able to specifically identify all "mixtures" and "compounds" and make the appropriate reimbursement to the pharmacist. In such situations, the dispensing fee is substantially more than the normal dispensing fee charged by the Pharmacist, and the $11.00 maximum will not apply.
2. For all "brand name drugs" that have a "generic substitute", only the "generic substitute" will be fully paid for, unless the doctor handwrites "no substitutes" on the prescription. If the employee/pensioner demands a "brand name product", he/she will have to pay the amount in excess of the price for the "generic substitute" at his/her expense.
For such drugs requiring a prescription by law and submitted electronically through AHI, there will be no delay. However, if the receipt is submitted on a paper claim it will need to be processed by Great-West Life through AHI and therefore will normally take 7 to 10 days longer to process than claims processed electronically through AHI.
All employees are required to use the drug card for all drugs purchased, except in cases where the card in not accepted by the dispenser – PAPER CLAIMS SHALL ONLY BE ACCEPTED IN APRIL AND OCTOBER. Claims submitted outside of April and October will be returned. AHI is a company that electronically processes drug claims for the Great-West Life Assurance Company and other insurance carriers. The Pharmacist inputs your name, employee number, the Electrical Safety Authority's group number, the Drug Identification Number (DIN), and the cost, for reimbursement. The majority of Pharmacies in Ontario have this capability. AHI is more efficient and requires no up-front, out-of-pocket, payment from the employee/pensioner, subject to the limits set out in number 1. above.
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When purchasing a drug using your Benefits Card, please be sure to give your Pharmacist the relationship of the patient and the accurate date of birth. Relationship is employee/pensioner, spouse, or child; plus the patient’s date of birth. If this information is not accurate, your claim will be rejected and the card will not work.
Over-the-counter “Life Sustaining” products that do not “require a prescription by law” will be covered effective January 1, 2007 if they are on The Company’s Drug Formulary identified as “Life-Sustaining”, and medically required for the treatment of an illness, injury or condition. That is, when prescribed by a doctor. The doctor should be asked to write out the information pertaining to over-the-counter products, separate from the drugs “requiring a prescription by law”.
There are two options for claiming the cost of over-the-counter products.
Option One - Dispensed by Pharmacist:
The Pharmacist can electronically submit the claim to AHI. The Pharmacist will be reimbursed up to a maximum dispensing fee equivalent to the dispensing fee set for the Ontario Drug Benefit (ODB) Plan (currently $6.11 per prescription). If the Pharmacist demands payment of a dispensing fee in excess of $6.11, the employee will have to (1) pay the excess amount, or (2) go to another Pharmacist who will agree to a dispensing fee at, or below, the ODB dispensing fee for over-the-counter products, or (3) go to Option Two below.
Option Two - Cash Register Receipt:
In April and October, employees can manually submit the original copy of the prescription, along with the sales receipt, to Great-West Life for reimbursement. Manual claims submitted outside of April and October will be returned. However, submissions for over-the-counter items will need to be accompanied by a separate prescription, and not combined with those requiring a prescription by law. Great-West Life must be able to readily identify the specific item on the sales receipt corresponding to the specific over-the-counter prescription in order to process the claim for the price of the over-the-counter product, plus the applicable sales tax. If the cash register receipt does not identify specific items, then the clerk should be asked to handwrite the name and drug identification number of the product and initial the sales receipt. In the case of "repeat over-the-counter prescribed
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drugs", employees and pensioners should attach a photocopy of the "original" doctor's prescription previously submitted to Great-West Life. If a photocopy is not available, you should advise Great-West Life that this is a "repeat prescription" when the original doctor's prescription is submitted with the first claim.
Option One is preferable for employees and The Company. It should be used whenever possible as it is more efficient, no sales tax is charged, no additional administration fee is charged, and there is no additional up-front, out-of-pocket, payment required on your part.
The following are some reasonable and customary limitations under the Drug Plan which normally apply. They are reviewed regularly in light of current community and medical practices.
Reimbursement to pharmacists for drugs is normally “wholesale price + 10%” (plus the dispensing fee if appropriate). This is generally referred to as Best Available Price (BAP).
When “generic substitution” was introduced in 1996 Executive employees, it was necessary to peg the price of the name brand drugs and their generic substitutes to prevent the price for the generic product from escalating up to, and surpassing, the price for the name brand product. As such, a cap was put on brand name drugs and the generic substitutes. The pharmacies understand this method of pricing as it is a common community practice and pharmacies tend to limit their charges to align with this procedure.
Smoking cessation products, such as nicorette gum, nicotine patch, or zyban, when prescribed by a physician, up to $1,000 per person per year.
Fertility drugs (those on the The Company Drug Formulary) up to 12 months, or a maximum cost of $5,000, whichever comes first, per lifetime.
4. Food supplements are generally not covered; except for (1) Nutramigen for children, prescribed by a physician, up to 85% of the cost, and (2) Ensure or Boost for very sick adults, prescribed by a physician.
Should you have any questions concerning drugs, you may phone Great-West Life or where there are special circumstances you wish considered, please contact Human Resources directly.