10 Summary of Maximum Eligible Expenses

Maximum of $8 for the pharmacy dispensing fee

The fee cap does not apply to biologic or compound drugs.

Pharmacist dispensing fees will be limited to 5 times per year for maintenance drugs.

Exceptions shall be granted if

1. the drug is a controlled substance,
2. the drug has a manufacturer recommended storage limitation, or
3. the prescribed drug’s three-month supply co-pay is more than $100.

5 refills

$400 every 2 calendar years commencing every odd year

No limit if required as a result of surgery or accident and purchased within 6 months of the event

Once in 60 months

In case of dependant children 21 years of age or less, 12 months of the last purchase

$1,500 less any eligible hearing aid expenses incurred and claimed during the previous 60 months

No limit if required as a result of surgery or accident and purchased within 6 months of the event

Once in 60 months for a member or dependant over 21 years of age

The frequency maximum may not apply if medically proven that growth or shrinkage of surrounding tissue requires replacement of the existing prosthesis.

$3,000 in a calendar year

Except needles and syringes are not eligible for the 36-month period following the date of purchase of an insulin jet injector device.

Once in 60 months

Excluding repair or replacement during the 60-month period following the date of purchase

$700 during a 60-month period, on a combined basis

Excluding repair or replacement during the 60-month period following the date of purchase

Once in a lifetime

Less all eligible lift/hoist repairs incurred prior to purchase

Once in 60 months

Less all eligible walker repair expenses incurred during the previous 5 years

Once in 60 months

Less any wheelchair expenses claimed for repairs during the previous 60 months

In case of dependant children, the 60-month maximum may not apply for medical necessity.

Replacement of wheelchairs within the 5-year limit shall be permitted when a patient’s medical condition changes and warrants a different type of chair. Reimbursement will be the eligible amount of the new chair less the amount reimbursed for the previously claimed chair.

Once in a lifetime

Less all eligible hospital bed repairs incurred prior to purchase

Once in 60 months

Less all eligible therapeutic mattress repairs incurred during the previous 5 years

Once in 12 months

Less all eligible wheelchair cushion repairs incurred during the previous 12 months

Once in a lifetime

Less all eligible apnea monitor repairs incurred prior to purchase

Once in 60 months

Less all eligible blood pressure monitor repairs incurred during the previous 5 years

Once in a lifetime

Less all eligible enuresis monitor repairs incurred prior to purchase

Once in 60 months

Less all eligible oxygen saturation meter repairs incurred during the previous 5 years

Once in 60 months

Less all eligible pulse oximeter repairs incurred during the previous 5 years

Once in 60 months

Less all eligible saturometer repairs incurred during the previous 5 years

Once in 60 months

Less all eligible coagulation monitor repairs incurred during the previous 5 years

Once in 60 months

Less all eligible heart monitor repairs incurred during the previous 5 years

Devices for mechanical and therapeutic support

Extremity Pump (Lymphapress)

Once in a lifetime

Less all eligible extremity pump repairs incurred prior to purchase

Infusion Pump

Once in 60 months

Less all eligible infusion pump repairs incurred during the previous 5 years

Traction Kit

Once in a lifetime

Less all eligible traction kit repairs incurred prior to purchase

Transcutaneous Electric Stimulator (TENS)

Once in 120 months

Less all eligible TENS repairs incurred during the previous 10 years

Devices for aerotherapeutic support

CPAP, BiPAP, or Related Dental Appliance

Once in 60 months

Less all eligible rentals and purchases of CPAP, BiPAP and dental appliance incurred during the previous 5 years

Repairs, Servicing, and Replacement Parts for Eligible Aerotherapeutic Devices (CPAP, BiPAP)

Compressor

Once in 60 months

Less all eligible compressor repairs incurred during the previous 5 years

Nebulizer

Once in 60 months

Less all eligible nebulizer repairs incurred during the previous 5 years

Out-of-Province Benefit

Emergency Benefit While Travelling/ Emergency Travel Assistance Services

$1,000,000 per period of travel (not exceeding 40 consecutive days, excluding any time out of the province for official travel status)

100%

$1,000,000 (CAD)

Family Assistance Benefit

$5,000 for any one travel emergency

100%

$5,000

Meals and Accommodations

$200 per day (combined)

100%

$200

Preparation and Return of the Deceased

$3,000

100%

$3,000

Referral Benefit

$25,000 per illness or injury

80%

$20,000 ($25,000 x 80%)

Hospital Provision

Level I

$90 per day

100%

$90

Level II

$170 per day

100%

$170

Level III

$250 per day

100%

$250

Basic Health Care Provision

3x the amount otherwise payable under the current fee schedule of the Health Insurance Act 1972 of Ontario

100%

Benefit

Duration of Prescription

Services of a nurse

One year, unless otherwise advised by the Plan Administrator

Services of an electrologist

Three years

A prescription is not required if electrolysis is required as a gender affirmation procedure.

Orthotics

Three years

Orthopaedic shoes

One year

Injectable lubricants for joint pain and arthritis

Three years

Needles and syringes (for the administration of injectable drugs)

Three years