| Maximum Eligible Expense per Participant | Reimburse ment |
Deductible1 | |
|---|---|---|---|
| Extended Health Provision as indicated below | |||
| Drug Benefit | 80% | yes | |
| Catastrophic drug coverage | Eligible drug expenses in excess of $3,000 out-of-pocket drug expense incurred in a given calendar year | 100% | yes |
| smoking cessation aids | $1,000 in a lifetime | 80% | yes |
| Erectile dysfunction drugs | $500 every calendar year on a combined basis | 80% | yes |
| Vision Care Benefit | 80% | yes | |
| eyeglasses/contact lenses (purchase and repairs) | $275 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 |
||
| eye examinations | 1 examination every 2 calendar years commencing every odd year | ||
| Medical Practitioners Benefit | 80% | yes | |
| Services of: | |||
| physiotherapist | up to $500 and over $1000 in a calendar year | ||
| psychologist | $1,000 in a calendar year | ||
| Social worker (Isolated Posts only) | $1,000 in a calendar year | ||
| massage therapist | $300 in a calendar year | ||
| osteopath | $300 in a calendar year | ||
| naturopath | $300 in a calendar year | ||
| Podiatrist, or chiropodist | $300 in a calendar year | ||
| chiropractor | $500 in a calendar year | ||
| speech language pathologist | $500 in a calendar year | ||
| electrologist (including treatment when performed by a physician) | $20 per visit | ||
| nursing services | $15,000 in a calendar year | ||
| Miscellaneous Expense Benefit | 80% | yes | |
| orthopaedic shoes | $150 in a calendar year | ||
| hearing aids (purchase/repairs) | $1,000 less any eligible hearing aid expenses 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 |
||
| orthopaedic brassieres | $200 in a calendar year | ||
| wigs | $1000 during a 60 month period | ||
| insulin jet injector device | $760 during a 36 month period | ||
| Durable Equipment | |||
| A. For Care | |||
| Devices for physical movement | |||
| walker | once in 60 months | ||
| lift/hoist | once in a lifetime | ||
| wheelchair (purchase/repairs) | 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. | ||
| Devices for support and resting | |||
| hospital bed | once in a lifetime | ||
| roho cushion | once in 12 months | ||
| therapeutic mattress | once in 60 months | ||
| Devices for monitoring | |||
| apnea monitor | once in a lifetime | ||
| enuresis detector | once in a lifetime | ||
| B. For Treatment | |||
| Devices for mechanical and therapeutic support | |||
| transcutaneous electric stimulator | once in 120 months | ||
| traction kit | once in a lifetime | ||
| infusion pump | once in 60 months | ||
| extremity pump (lymphapress) | once in a lifetime | ||
| Devices for aerotherapeutic support | |||
| CPAP's, BiPAP's, related dental appliances | once in 60 months | ||
| compressor | once in 60 months | ||
| maximist | once in 60 months | ||
| Out-of-Province Benefit | |||
| Emergency Benefit While Travelling / Emergency Travel Assistance Services | $500,000 per period of travel (not exceeding 40 consecutive days) | 100% | none |
| Referral Benefit | $25,000 per illness or injury | 80% | yes |
| Hospital Provision | |||
| Level I | $60 per day | 100% | none |
| Level II | $140 per day | 100% | none |
| Level III | $220 per day | 100% | none |
| Basic Health Care Provision | 3x the amount otherwise payable under the current fee schedule of the Health Insurance Act 1972 of Ontario | 100% | none |
1 The deductible is $60 per person, $100 per family. The deductible applies per calendar year to the combined eligible expenses under the Extended Health Provision.
Length of time a prescription is valid
| BENEFIT | DURATION OF PRESCRIPTION |
|---|---|
| services of a physiotherapist | one year |
| services of a massage therapist | one year |
| services of a speech language pathologist | one year |
| services of a psychologist | one year |
| Services of a social worker (isolated post) | one year |
| services of a nurse | one year, unless otherwise advised by the Administrator |
| services of an electrologist | three years |
| orthotics | three years |
| orthopaedic shoes | one year |
Note: Unless otherwise requested by the Administrator, all other prescriptions do not have a time limit.