Extended Health and Vision Coverages

Government health plans can provide coverage for such basic medical expenses as hospital charges and doctors’ fees. Often, however, it is necessary to obtain care or treatment that goes beyond “basic” in order to maintain well being and quality of life. In such cases, financial hardship can be crippling if help in the form of extended coverage is not available.

Private health care supplements government plans and can provide benefits not available through any government plan. This program provides you with peace of mind and security in the knowledge that financial assistance will be provided when you and your family need it most.

coverage provided by Manulife Financial

The plan coverages described below apply to both active and retired plan members

Extended Health Care Overview

Overview of Extended Health Care Benefits

Overall benefit maximum:        Unlimited
Deductible:                                   None

Covered Expenses

The expenses specified are covered to the extent that they are reasonable and customary, as determind by Manulife Financial, provided they are:

  • Medically Necessary for the treatment of an illness or injury of an insured person and recommended by a Physician;
  • incurred for the care of a person while he is insured under this Group Benefit Program;
  • reasonable taking all factors into account;
  • not covered under the Provincial Plan or any other government-sponsored program;
  • legally insurable;
  • used as prescribed or recommended by a Physician; and
  • supported by Manulife’s Due Diligence process and due diligence for the drug, supply or service has been completed where required.

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 formerly covered in full or in part by such plan or program, this Policy 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 change, whether the expenses will be considered eligible or not.

This Policy will not automatically assume eligibility for all Drugs, services and supplies prescribed. New Drugs, existing Drugs with new indications, services and supplies are reviewed by Manulife Financial using the Due Diligence process. Once this process has been completed, the decision will be made by Manulife Financial to include, with Prior Authorization criteria, exclude or apply maximum limits.

Manulife Financial 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 Alternative treatments, a person may be required to have tried an alternative treatment.

At Manulife Financial’s discretion, medical information, test results or other documentation may be required from the Physician to determine the eligibility of the Drug, service or supply.

Manulife Financial has the right to ensure insured persons access Manulife Financial’s Exclusive Distribution channels where applicable when purchasing a Drug, service or supply. Manulife Financial may decline a Drug, service or supply purchased from a provider outside the Exclusive Distribution channel.

Advance Supply Limitation

Payment of any Covered Expenses under this Benefit which may be purchased in large quantities will be limited to the purchase of up to a 3 months’ supply at any one time, except of covered Drug expense ( see next section).

Adherence

Non-compliance may result in the Drug, service or supply no longer being eligible for reimbursement.

Disease Management Programs

Participation in a Disease Management Program may be required. Participation will be at the discretion of Manulife Financial.

Patient Assistance Programs

Manulife Financial may require an insured person to apply to and participate in any Patient Assistance Program to which the insured person is entitled. Manulife Financial reserves the right to reduce the amount of a Covered Expense by the amount of financial assistance the insured person is entitled to receive under a Patient Assistance Program.

Prescription Drugs

Coverage: 80% until $250 Out-of-Pocket Maximum per person is reached every calendar year; then 100% to a maximum of $1,000,000 per person per calendar year.

The ManuScript Generic Drug Plan 2 provides you and your Dependents with convenient Canada-wide coverage on your prescription Drug requirements.

Your Benefit is a Generic Drug plan, which means:

  • The maximum amount for any Covered Expenses is the price of the Lower Cost Alternative Drug that can legally be used to fill the prescription, as listed in the Provincial Drug Benefit Formulary or a Lower Cost Alternative that provides therapeutically similar results as identified by Manulife Financial. (Subject to coinsurance and maximums).
  • Manulife Financial can limit the Covered Expense for any Drug to that of a lower cost interchangeable Drug at the time the Drug is purchased.
  • If there is no Lower Cost Alternative Drug for the prescribed Drug. the amount payable is based on the cost of the prescribed Drug. (Subject to coinsurance and maximums.)
  • If your prescription contains a written direction from your Physician or Dentist that the prescribed Drug or medicine is not to be substituted with another product, and if the prescribed product is a covered expense under this benefit, the full cost will be covered. (Subject to coinsurance and maximums.)

My drug plan tool is a personalized user friendly online tool to provide you with information what is covered and information about the drugs you are prescribed. Access My Drug Plan member eCard by computer, tablet or mobile device.

Charges incurred for the following expenses are payable when prescribed in writing by a Physician or Dentist, and dispensed by a Licensed pharmacist:

  • Drugs for the treatment of a sickness or injury, which by law or convention require the written prescription of a Physician or Dentist;
  • oral contraceptives;
  • injectable medications (charges for a practitioner or Physician to administer injectable medications are not covered);
  • life-sustaining drugs;
  • preventive vaccines and medicines (oral or injected);
  • standard syringes, needles and diagnostic aids, required for the treatment of diabetes.

Charges that are not covered include:

  • Drugs, biologicals and related preparations which are administered in Hospital on an in-patient or out-patient basis;
  • Drugs determined to be ineligible as a result of Due Diligence;
  • fertility Drugs, anti-smoking Drugs and anti-obesity Drugs;
  • Drugs used in the treatment of a sexual dysfunction
  • cotton swabs, rubbing alcohol, automatic jet injectors and similar equipment generally used in the treatment of diabetes.

Advance Supply Limitation

The maximum quantity of Drugs or medicines that will be payable for each prescription will be limited to the lesser of:

  • the quantity prescribed by your Physician or Dentist, or
  • a 34-day supply.

A quantity of up to a 100-day supply may be payable in long-term therapy cases, where the larger quantity is recommended as appropriate by your Physician and pharmacist.

Making a Claim

A plan member can simply present their Manulife Financial Card and a valid prescription at any pharmacy in Canada displaying the Pay Direct Drug decal.

After entering card and prescription information, the pharmacist advises what is covered under the plan, and what the plan member’s payment will be. You will be required to pay only those amounts not covered by your plan. You may obtain additional Manulife Financial Cards for your registered Dependents, but all cards will be in your name.

If you do not have access to a participating pharmacy, if you do not have your Manulife Financial Card with you at the time of purchase, or if your prescription is not available through the Pay Direct system, you must pay the entire amount and submit a claim for the covered benefit

Specialty Drug Care

Specialty Drug Care is a new program (effective February 1, 2015).

The Specialty Drug Care program includes a preferred pharmacy network, pharmacy services, preferred pricing and case management services for Specialty Drugs. Specialty Drugs, as determined by Manulife Financial, are high cost medications used to treat complex chronic and life-threntening conditions; they may rquire special storage, handling and administration, (including injection and infusion), and involve a significant degree of patient education, monitoring and management. The services described below are applicable to insured persons who enroll in this program.

Case management services may include but are not limited to:

  1. program introduction;
  2. arrangement for medication dispensing and distribution;
  3. desease and medication education;
  4. therapy optimization;
  5. coordination of efficacy tests to ensure therapy is working;
  6. health coaching in 4 areas: nutrition, physical activity, smoking cessation and stress;
  7. assistance locating and in applying for alternative sources of funding, which may include patient assistance programs or provincial funding;
  8. coordination and transfer of prescriptions to the network pharmacy;
  9. medication adherence monitoring; and
  10. support with side effect managements.

The amount of health case management services will vary depending on the diagnosis, Drug and recommended treatment plan.

Specialty Drug Care pharmacy services include:

  1. preferred pricing;
  2. specialty medication management and expertise;
  3. drug delivery to the location of choice – home, infusion clinic, or doctor’s office;
  4. access to a 24/7 pharmacist hotline for consultation;
  5. expertise in cold chain (temperature sensitive) drug managment and shipping; and
  6. expertise in managing infusions, injections, education and high touch oncology and biologic medication management.

Payment of Specialty Drugs

Where a Drug has been determined to be eligible under the Plan, and where other Drugs will provide therapeutically similar results, the program will provide and reimburse the lowerst cost alternative Drug. In cases where the Physician provides medical evidence that the alternate Drug cannot be tolerated, or is ineffective for the pateient, the prescribed Drug will be eligible for consideration. (Subject to maximums and co-insurance).

Manulife Financial may require the insured person to apply to and participate in any patient assistance program to which the insured person is entitled. Manulife Financial will co-ordinate benefits payable under the Policy with any benefits payable through a patient assistance program.

Due to current regulation in Quebec, Manulife Financial is unable to offere a preferred provider network in the province. At such time as the regulations change, Manulife Financial will make these services available.

Vision Care

Coverage is provided for charges for the following Vsion Care expenses when prescribed by an ophthalmologist. optometrist, or oculist:

  • eye exams including refractions, once per 12 months for persons under age 18 and once per 24 months for person 18 and over;
  • purchase and fitting of prescription glasses or elective contact lenses, as well as repairs, or elective laser vision correction procedures, up to $250 during any 24 months.
  • contact lenses if prescribed as medically necessary or required to improve vision to at least a 20/40 level with in the better eye, provided this level cannot be attained with glasses, up to $200 during any 24 months.
  • visual training, up to the $200 per lifetime.

Professional Services

Coverage: 100%, subject to maximums and limitations in the table below. 
Please note that the maximums are applied to the plan member and each dependent.

Services provided by the following Certified, Licensed or Registered practitioners:

PractionersMaximums & Limitations
Acupuncturist$500 per calendar year
Audiologist$500 per calendar year
Chiropodist$500 per calendar year
Chiropractor$500 per calendar year, plus $50 per calendar year for x-rays
Dietitian$500 per calendar year, the recommendation of a Physician is required
Osteopath$500 per calendar year
Podiatrist$500 per calendar year
Massage Therapist$500 per calendar year
Naturopath$500 per calendar year
Speech Therapist$500 per calendar year
Physiotherapist / Athletic Therapist / Kinesiologist$500 per calendar year (combined)
Psychologist / Marriage and Family Therapist (MFT) / Masters in Social Work (MSW) / Registered Social Worker (RSW)$5,000 per calendar year (combined)
effective January 1, 2017 ($500 until then)

Provincial Plans may pay part of the expenses for some of these Professional Services. Coverage for the balance of such expenses prior to reaching the Provincial Plan maximum may be prohibited by provincial legislation. In those provinces where such prohibition exists, expenses under this Benefit Program are payable after the Provincial Plan’s maximum for the benefit year has been paid.

Medical Services and Supples

Private Duty Nursing

Coverage: 100% to a maximum of $10,000 per calendar year.

Please note that the maximums are applied to the plan member and each dependent.

Covered Expenses include services which are deemed to be within the practice of nursing and which are provided in the patient’s home by:

  • a registered nurse, or
  • a registered nursing assistant (or equivalent designation) who has completed an approved medications training program.

It is recommended that a detailed treatment plan with cost estimates be submitted before private duty nursing services begin, so that you can be advised of any benefit that will be provided.

Charges for the following services are not covered:

  • service provided primarily for custodial care, homemaking duties, or supervision;
  • service performed by a nursing practitioner who is an Immediate Family Member or who lives with the patient;
  • service performed while the patient is confined in a hospital, nursing home, or similar institution;
  • service which can be performed by a person of lesser qualification, a relative, friend, or a member of the patient’s household.

Ambulance

Coverage: 100%

Licensed ambulance service, including air ambulance, is provided in the patient’s province of residence to transfer the patient to the nearest hospital where adequate treatment is available.

Medical Equipment and Supplies

Coverage: 100%, with the exception of insulin pumps covered at 50%, subject to maximums and limitations.

For all medical equipment and supplies covered under this provision, Covered Expenses will be limited to the cost of the device or item that adequately meets the patient’s fundamental medical needs and is approved by Manulife Financial.

For all medical services and supplies expenses Manulife Financial requires a written recommendation from the prescribing physician, including diagnosis, and a copy of the provincial plan statement of payment (if applicable).

Medical Supplies
Maximums and Limitations
Mobility equipment such as crutches, canes, walkers and wheelchairs (1)rental of, or when pre-approved by Manulife Financial, the purchase of
Durable medical equipment including manual hospital beds, respiratory and oxygen equipment, and other durable equipment usually found only in hospitalsrental of, or when pre-approved by Manulife Financial, the purchase of
External prostheses
Surgical stockingsA maximum of 4 pairs per calendar year
Surgical brassieresA maximum of 4 per calendar year
Braces (other than foot braces), trusses, collars, leg orthosis, casts and splints
Stock-item orthopaedic shoes (2) and modifications or adjustments to stock-item orthopaedic shoes (2) or regular footwearA maximum of $150 per calendar year (recommendation of either a Physician or a podiatrist is required)
Custom-made shoes which are required due to a medical abnormality that, based on medical evidence, cannot be accommodated in a stock-item orthopaedic shoe or a modified stock-item othopaedic shoeA maximum of 1 pair per calendar year (must be constructed by a Certified orthopaedic footwear specialist)
Casted, custom-made orthotics (3)A maximum of $400 per 3 calendar years (recommendation of either a Physician or a podiatrist is required)
Hearing aids - cost, installation, repair and maintenance of hearing aids (including charges for batteries)A maximum of $1,000 every 5 calendar years
Ileostomy, colostomy and incontinence supplies
Medicated dressing and burn garments
Wigs and hairpieces for patients with temporary hair loss as a result of medical treatment or a medical conditionA maximum of $500 per lifetime
Oxygen
Microscopic and other similar diagnostic tests and services rendered in a Licensed laboratory in the province of Quebec
Charges for the treatment of accidental injuries to natural teeth or jaw, provided the treatment is rendered within 12 months of the accident, excluding injuries due to biting or chewing

(1) Wheelchair claim guide

(2) Orthopaedic Shoes claim guide

(3) Orthotics_memberguide

What the Extended Health Plan Does Not Cover

No Extended Health Care benefits are payable for expenses related to:

  • self-inflicted injuries;
  • war, insurrection, the hostile actions of any armed forces, or participation in a riot or civil commotion;
  • committing or attempting to commit an assault or criminal offence;
  • injuries sustained while operating a motor vehicle while under the influence of any intoxicant, including alcohol;
  • an illness or injury for which benefits are payable under any Government Plan or Workers’ Compensation;
  • charges for periodic check-ups, broken appointments, third party examinations, travel for health purposes, or completion of claim forms;
  • services or supplies provided by an employer’s medical or dental department;
  • services or supplies for which no charge would normally be made in the absence of insurance;
  • services and supplies where reimbursement would have been made under a government-sponsored plan, in the absence of insurance;
  • services or supplies which are not permitted by law to be paid;
  • services or supplies which are required for recreation or sports;
  • services or supplies which would have been payable by the Provincial Plan if proper application had been made;
  • medical treatment which is unusual, or is Experimental or Investigational in nature;
  • medical or surgical care which is cosmetic;
  • services or supplies which are performed or provided by the insured person, an Immediate Family Member or a person who lives with the insured person;
  • services or supplies which are provided while confined in a hospital on an in-patient basis;
  • services or supplies which are not specified as a covered expense under this benefit.

Subrogation (Third Party Liability)

If your medical expenses result from an injury caused by another person and you have the legal right to recover damages, the insurer may request that you complete a subrogation reimbursement agreement when you submit a claim for such expenses.

On settlement or judgment of your legal action, you will be required to reimburse the insurer those amounts you recover which, when added to the payments you received from the insurer, exceed 100% of your incurred expenses.

Drug Benefit for Persons Living in Quebec

The following expenses are covered:

  • drugs that are on the List of Insured Drugs that is published by the Régie de l’assurance-maladie du Québec (RAMQ List), provided such drugs are on the list at the time the expense is incurred; and
  • drugs that are listed as a covered expense in this information package, but are not on the RAMQ List.

Coverage for drugs on the List of Insured Drugs that is published by the Régie de l’assurance-maladie du Québec (RAMQ List)

The following provisions apply only to the coverage of drugs that are on the RAMQ List, as legislated by An Act Respecting Prescription Drug Insurance (R.S.Q. c., A-29-01). Coverage for all other drugs will be subject to the regular provisions included in this information package:

a) Benefit Percentage

Prior to the annual out-of-pocket maximum being reached, the percentage of covered drug expenses payable under this benefit will be as follows:

  • For any drug on the RAMQ List which is not otherwise covered under the terms of this Benefit, the percentage payable is the percentage as set out by the then applicable Legislation.
  • For any drug on the RAMQ List which is covered under the terms of the prescription drug coverage provision described in the extended health care tab, the percentage payable is the greater of:
  • the benefit percentage stated under the prescription drug coverage provision described in the extended health care tab; and
  • the percentage as set out by the then applicable Legislation.

After the annual out-of-pocket maximum has been reached, the percentage of covered drug expenses payable under this benefit will be 100%.

b) Annual Out-of-Pocket Maximum

The annual out-of-pocket maximum is the portion of covered drug expenses which must be paid by you and your spouse in a calendar year, before the percentage payable under this benefit will be 100%.

Amounts that will be applied to the annual out-of-pocket maximum are:

  • deductible amounts, and
  • the portion of covered drug expenses that is paid by an insured person, when the percentage of covered expenses payable under this benefit is less than 100%.

The annual out-of-pocket maximum for you and your spouse is as stipulated in the Legislation and includes those portions of covered drug expenses paid for your dependent children.

For the purposes of calculating the out-of-pocket maximum for you and your spouse, those portions of covered drug expenses paid for your dependent children will be applied to the person who is closest to reaching the annual out-of-pocket maximum.

c) Deductible

Deductible amounts (if any) for the drug benefit will apply, until the annual out-of pocket maximum is reached. Thereafter, the deductible will not apply.

d) Lifetime Maximums

Lifetime maximums (if any) for the drug benefit will not apply. Drug coverage provided after the lifetime maximum stated under the prescription drug coverage provision described in the extended health care tab is reached, is subject to the following conditions:

  • only drugs that are on the RAMQ List are covered, and
  • the percentage payable by Manulife Financial for covered expenses is the percentage as set out by the then applicable Legislation.

e) Eligible Dependent Children

Your eligible dependent children who are in full-time attendance at an accredited educational institution will be covered until the later of:

  • the age specified in the glossary, and
  • age 26.

Drug coverage provided for dependent children after the age specified in the glossary is subject to the following conditions:

  • only drugs that are on the RAMQ List are covered, and
  • the percentage payable by Manulife Financial for covered expenses is the percentage as set out by the then applicable Legislation.

f) Termination Age

Provided you are otherwise eligible for the drug benefit, the Termination Age (if any) for the drug benefit will not apply. Drug coverage provided after the Termination Age specified under the prescription drug coverage provision described in the extended health care tab is subject to the following conditions:

  • only drugs that are on the RAMQ List are covered,
  • the percentage payable by Manulife Financial for covered expenses is the percentage as stipulated in the then applicable Legislation,
  • the Annual Out-of-Pocket Maximum is as stipulated in the then applicable Legislation,
  • the premium required for the drug coverage is the premium for Extended Health Care,

Coverage for Drugs That are Listed as a Covered Expense in This Information Package but are not on the RAMQ List

Coverage for drugs that are listed as a covered expense under this Benefit but not on the RAMQ List will be subject to all the standard provisions included in this information package.