Medical Plan

The medical plan provides coverage for a healthier you. You’ll find more detail on what’s covered in the plan booklet.

Payment

You pay an annual deductible of $50 per person, up to $100 per family. Then the plan covers most prescription and medical expenses at 80%.

At the pharmacy, you’ll present your Pay Direct Drug card, and you'll pay your portion of the covered cost of the medication out of pocket.

For other medical expenses, you’ll pay upfront and submit a health claim form (English version, French version) directly to Sun Life for reimbursement.

After you satisfy the annual deductible, the plan covers most prescriptions at 80%.

The prescription must be written by a physician or dentist and be dispensed by a licensed pharmacist or physician legally authorized to dispense medications. If you purchase a brand name drug when a generic substitute is available, the plan will reimburse only the covered cost of the generic drug. When there is more than one drug that is suitable to treat your condition, our plan allows for reimbursement based on the lowest priced drug. Should you decide to purchase a higher priced drug, you must pay the difference between the ingredient cost for the drug purchased and the ingredient cost for the lowest priced drug. If the doctor provides written direction that the drug is not to be substituted, the full cost of the prescribed product will be covered (provided it is a covered expense under the Plan).

Smoking cessation aids that require a physician's prescription are covered, subject to a lifetime maximum benefit of $500 per individual.

  • Fertility drugs, laboratory tests, X-rays and related ultrasound
  • General supplies
  • Fees for the services of physicians, nurses, technicians, anesthetists, and administrative staff
  • No benefit will be payable for any single purchase of drugs that would not reasonably be used within 90 days from the date of purchase.

The plan covers the following care and services.

Hospital Care

Hospital Care (Other than Chronic Care) – A semi-private room is covered 100%.

Convalescent Care

Convalescent Care Facility – A semi-private room is covered with a  $20 copay per day, maximum of 180 days per disability. Confinement must begin following a minimum of three consecutive days of hospital confinement.  

Hospital Care (Other than Chronic Care) – A semi-private room is covered 100%.

Convalescent Care Facility – A semi-private room is covered with a $20 copay per day, maximum of 180 days per disability. Confinement must begin following a minimum of three consecutive days of hospital confinement.

  • Eye Exams are covered 100% up to $50 every two benefit years.
  • Prescription Glasses are covered 100% up to $250 every 24 months.
  • Contact Lenses (medically necessary or to improve vision to at least 20/40 in the better eye if not correctable by eyeglasses) are covered 100% up to $200 every 24 months.
  • Preferred Vision Services Inc. (PVS) is a network of optical outlets (national chains and independent retailers) that can offer you significant savings on prescription eyewear products through its participating stores. PVS is offered as an enhancement to your Sun Life Financial Group Benefits health care coverage. Visit Preferred Vision Services for more information.

Charges for the services of a licensed speech therapist, clinical psychologist, osteopath, chiropractor, physiotherapist, registered naturopath (ND – Naturopathic Doctor), podiatrist, masseur or Christian science practitioner are reimbursed after deductible at 80% up to a combined maximum benefit of $500  for all practitioner visits, in excess of the Provincial Plan.

  • Private Duty Nursing
  • Rental of Major Medical Equipment
  • Non-dental Prosthesis, Supports and Hearing Aids
  • Custom-made Orthopaedic Shoes: $200 per shoe up to a maximum of $400 per calendar year combined with Orthotics, and adjustments and modifications to stock item Orthopaedic Shoes
  • Custom-Made Orthotics: $400 per calendar year, combined with Custom-made Orthopaedic Shoes, as well as adjustments and modifications to stock item Orthopaedic Shoes
  • Hearing Aids: $500 per five (5) consecutive benefit years
  • Surgical Stockings and Brassieres: up to two each per benefit year
  • Wigs and Hairpieces: up to $300 per wig, two (2) wigs within a five (5) year period

Out-of-Province or Out-of-Canada:

  • Charges incurred for necessary medical treatment given outside the covered person’s province of residence.
  • Treatment required as a result of a Medical Emergency arising during the first 60 days while temporarily outside the province of residence, provided that the covered person who receives the treatment is also covered by the Provincial Plan during the absence from the province of residence.

A Medical Emergency is a sudden, unexpected injury that occurs or an unforeseen illness that begins while a covered person is traveling outside their province of residence and requires immediate medical attention. Such emergency no longer exists when, in the opinion of the attending physician and supporting medical evidence, the covered person is stable enough to return to the province of residence.

The plan will cover out-of-province or out-of-Canada eligible expenses after deductible at 80%. The member is responsible for paying an out of pocket maximum of $3,000 per person or $6,000 per family. The paid maximum benefit is $3,000,000 per lifetime.

Limited Emergency Travel Assistance:

  • Ileostomy, Colostomy, and Incontinence Supplies
  • Oxygen
  • Medicated Dressings and Burn Garments

 

Ambulance within the patient's province to transport the patient to the nearest hospital.

Dental Care, limited to the treatment of accidental injuries to the natural teeth or jaw. The accident must be due to a force or blow external to the mouth and have occurred while the person was covered for this benefit. The treatment must be received and approved for payment within 12 months of the accident.

The firm will coordinate payment of medical, emergency travel assistance and dental benefits so that benefits from all plans do not exceed 100% of the eligible claim. For this purpose, the Insurer has a right to receive and release information on benefits and collect any overpayments, if necessary.

  • Any illness or injury arising out of or in the course of employment when the person is insured by or is eligible for coverage by Workers’ Compensation
  • Any illness or injury for which benefits are payable under any government plan or legally mandated program
  • Self-inflicted injuries or illnesses, whether the person is sane or insane
  • War, insurrection, the hostile action of any armed forces or participation in a riot or civil commotion
  • The committing of or the attempt to commit an assault or criminal offence
  • Injuries sustained while operating a motor vehicle, either while under the influence of any intoxicant or if the covered person’s blood contained more than 80 milligrams of alcohol per 100 millilitres of blood at the time of injury
  • Charges for periodic check-ups, broken appointments, third-party examinations, travel for health purposes, or completion of claim forms
  • Charges for services or supplies when there would have been no charge at all in the absence of plan benefit coverage
  • When reimbursement would have been made under a government-sponsored plan in the absence of plan benefit coverage
  • Expenses required for recreation or sports but that are not medically necessary for regular activities
  • Expenses that would have been payable by the Provincial Plan if proper application had been made
  • Expenses that are provided while confined in a hospital on an in-patient basis
  • Cosmetic expenses
  • Expenses above the usual and customary amounts or experimental or investigational expenses