BCGEU Okanagan

Extended Health Care Benefits for BCGEU Okanagan Employees

The UBC Benefits Extended Health Care Plan provides coverage for some medical services and supplies that are not covered under your provincial medical plan (in BC, this is the Medical Services Plan, MSP).

Extended Health Plan Premiums Group Number: 25205 You Pay UBC Pays Single — $32.78 Single plus dependant — $109.48 Family — $109.48

Important note: This is only a brief overview of the plan. For complete details, refer to the Sun Life benefits booklet.

In general, the Extended Health Care plan covers you for physician-recommended medically necessary services and supplies, and will pay reasonable and customary charges for these services.

When coverage begins: the first of the month on or after your date of hire, or the first of the month on or after your application is received by Financial Services, if you did not enroll when you first became eligible.

Note: You must be eligible for and enrolled in a Canadian public health plan (such as MSP) either through UBC or another benefit plan in order to be eligible to enroll in UBC’s Extended Health plan.  If you are arriving to British Columbia from out-of-country, you must satisfy the British Columbia Medical Services Plan (MSP) waiting period (consists of balance of the month you arrive in BC plus two full months) before you can enroll in UBC’s Extended Health plan.

When coverage ends: your coverage ends on the earliest of the following dates:

1) the date you elect to voluntarily cancel your coverage;

2) the last day of the month in which your employment ends or you choose to retire, if the date the employment status changed is between the 1st and the 15th of the month;

3) the last day of the month following the month in which your employment ends or you choose to retire, if the date the employment status changed is between the 16th and the last day of the month;

4) the end of the month prior to the date you elect your UBC Staff Pension Plan retirement income/benefit option(s), if you continue to work past your normal retirement date;

5) the end of the calendar year in which you reach the maximum pensionable age as defined by the Income Tax Act (Canada), if you continue to work past your normal retirement date.  The maximum pensionable age at January 1, 2008 as defined by the Income Tax Act is 71.

Lifetime Maximum: $1,000,000 per person

Deductible: $25 each benefit year (Jan. 1 – Dec. 31) for each person up to a maximum of $25 per family (The deductible is the portion of claims that you are responsible for paying.)

Who Qualifies As Your Dependent:

Your dependent must be your spouse or your child and a resident of Canada and covered under a provincial medicare plan (such as the Medical Services Plan) or federal government plan that provides similar benefits.

• Your spouse by marriage or under any other formal union recognized by law, or your partner of the opposite sex or of the same sex who is publicly represented as your spouse. You can cover only one spouse at a time.
• Your children, your spouse’s children (other than foster children), or children for whom you or your spouse is the primary caregiver and granted custody and control, if they are not married or in any other formal union recognized by law, and are under age 19.
• Your children, your spouse’s children (other than foster children), or children for whom you or your spouse is the primary caregiver and granted custody and control, if they are full-time students attending an educational institution recognized under the Income Tax Act (Canada) and entirely dependent on you for financial support, up to age 25.
• Your children, your spouse’s children (other than foster children) or children for whom you or your spouse is the primary caregiver and granted custody and control, if they become incapable of financial self-support because of a physical or mental disability. There is no age limit as long as your child is diagnosed with a disability before age 25 and entirely dependent on you for financial support and not married or in any other formal union recognized by law.

If you require proof that your dependent is covered under the UBC Extended Health Plan, please email us at benefitsinfo@hr.ubc.ca.

Disclaimer: This outline is a descriptive outline of the plan only; it is not a contract. All terms and conditions are governed by Contract Number 25205 with Sun Life Assurance Company of Canada. In the event of a discrepancy, benefits will be paid according to the official document and applicable legislation.

Reimbursement Level for Eligible Expenses

After your deductible has been satisfied for the benefit year, you will be reimbursed at the following levels up to your lifetime maximum:

Prescription Drugs

• BC PharmaCare Formulary drugs: 85%*
• Non BC PharmaCare Formulary drugs: 70%*

In-Province Hospital: 80%*

Medical Services & Equipment: 80%*

Paramedical Services: 80%*

Vision Care: 100%

Emergency Out-of-Province Medical Care: 100%

*Coverage is 80% until $1,000 is reimbursed per person per benefit year for prescription drugs, in-province hospital, medical services and equipment and paramedical services combined. Thereafter, eligible expenses are paid at 100% for the remainder of the benefit year.

A. Prescription Drugs (85% / 70%)

Have You Confirmed your Fair PharmaCare registration?

What the Plan Covers

The plan covers eligible prescription drugs, as long as they are prescribed by a physician or dentist and are obtained from a pharmacist, including prescribed and over-the-counter smoking cessation drugs (added effective January 1, 2011). 

Sun Life will cover the cost of prescription drugs up to the cost of the lowest priced generic equivalent, unless the doctor specifies in writing that no substitution for the prescribed drug may be made. 

The maximum for smoking cessation drugs is $300 per person per benefit year.

What the Plan Does Not Cover

The plan will not cover all drugs or medicines, even when they are prescribed. It is important that you review the specific coverage in the Sun Life benefits booklet.

Some examples of what is not covered include the cost of giving injections, treatments for weight loss if not medically necessary, hair growth stimulants, infant formulas or fertility drugs.

Catastrophic Drug Claim Appeal Policy

In response to a demand for catastrophic drug coverage, UBC has developed guidelines under which a claims adjudicator is appointed to examine cases and to assist active status faculty and staff members facing financial hardship as a result of requiring expensive drug therapy for themselves or their eligible dependents for catastrophic illnesses. This policy also seeks to ensure safe, appropriate, and effective utilization of specialty drug therapies that is supported by Health Canada and ongoing medical research.

A third-party adjudicator will review the claims based on criteria listed in the Catastrophic Drug Claim Appeal Policy document. All decisions by the claims adjudicator are final.

Please contact UBC Benefits at benefitsinfo@hr.ubc.ca, or 604-822-6823, with any questions, or to initiate a claim.

B. In-Province Hospital (80%)

What the Plan Covers

The plan will cover costs of hospital care, and the cost difference between a room on a general hospital ward and a semi-private or private hospital room.

What the Plan Does Not Cover

This benefit does not cover hospital outpatient fees and user fees, or care in a nursing home, rest home or alcohol or drug abuse treatment centre, even if located in a hospital.

C. Medical Services & Equipment (80%)

What the Plan Covers

The plan covers a wide variety of medical services and equipment, when ordered by a doctor (the services of a dentist does not require a doctor’s order).

Some of the services and equipment covered in this category include: private duty nursing care in-hospital or out-of-hospital (added effective January 1, 2011), if medically necessary, transportation in a licensed ambulance or air ambulance, accidental dental services, equipment recommended for therapeutic use, hearing aids, blood transfusions and dialysis machines.

What the Plan Does Not Cover

There are some items that are not covered under the plan, even when a doctor prescribes them. Some of these are: experimental treatments, personal comfort items, services and supplies for cosmetic purposes, or the services of a licensed practical nurse.

D. Paramedical Services (80%)

What the Plan Covers

The services of some paramedical practitioners are covered under the plan, with maximum annual costs specified for each discipline.

The practitioners covered under the plan are:

• licensed psychologist or licensed social workers*, when ordered by a doctor (up to a maximum of $1,200 for each person per benefit year);
• licensed speech therapist, acupuncturist, chiropractor, naturopath, homeopath, podiatrist, chiropodist,  osteopath*, dietician**, audiologist** or occupational therapist** (up to a combined maximum of $600 for each person per benefit year);
• licensed physiotherapist or massage therapist when ordered by a doctor (up to a combined maximum of $750 for each person per benefit year).

Licensed psychologists and massage therapists require doctor’s referral every 12 months.

*Added effective August 1, 2010.

**Added effective July 1, 2011.

Reasonable & Customary Charges

Most medical services providers and suppliers charge a range of fees for certain services, including paramedical services. 

Benefit providers, such as Sun Life, determine “reasonable and customary” charges as the basis for reimbursing your claims, which are also subject to the reimbursement level and maximums specifed under the Extended Health Care plan.  Sun Life’s reasonable & customary charges by paramedical practitioner in each province is outlined in the Reasonable & Customary Charges for Paramedical Services document. 

What the Plan Does Not Cover

The following are not covered under the Plan: the services of religious or spiritual healers; services of a kinotherapist, reflexologist, sexologist, sex therapist and shiatsu specialist.

E. Vision Care (100%)

What the Plan Covers

Contact lenses or eyeglasses prescribed by a licensed optometrist or ophthalmologist, eye exams and prescription sunglasses. Laser eye correction surgery, when performed by an ophthalmologist, is also covered under the plan.

The plan will cover up to a maximum of $400 in any 24-month period. At any given time, the amount you are eligible to claim is the maximum of $400, less the amount of any benefit which has been paid to you during the previous 24 months.

One pair of contact lenses or intraocular lenses following cataract surgery, when not covered by the provincial medicare plan (added effective July 1, 2011).

What the Plan Does Not Cover

The plan does not cover the cost of magnifying glasses or safety glasses of any kind.

F. Custom-Made Orthopaedic Shoes and Custom-Made Orthotic Inserts (80%)

What the Plan Covers

The plan covers custom-made orthotic inserts for shoes, excluding arch supports, when prescribed by a doctor, podiatrist or chiropodist, up to a maximum of $200 in a benefit year for eligible dependents under age 19 or a maximum of $400 in a benefit year for any other person.

The plan covers custom-made orthopaedic shoes or modifications to orthopaedic shoes when prescribed by a doctor, podiatrist or chiropodist, up to a maximum of $200 in a benefit year for eligible dependents under age 19 or a maximum of $400 in a benefit year for any other person.

A detailed lab invoice issued to the provider of the service (i.e. the person dispensing the shoes or orthotics to you) by the manufacturer of the custom-made shoes and/or orthotics must be submitted with the claim.   This invoice should include an itemized breakdown of the raw materials used, their cost and any other associated costs incurred to manufacture the custom-made shoes or orthotics. If the costs relate to shoe modifications, the details and cost of each modification must be present.

G. Emergency Out-of-Province Medical Care (100%)

For full information on your benefits while travelling outside BC and Canada, visit our Travel benefits section.

What the Plan Covers

The plan will cover emergency medical services obtained within 365 days of the date you leave your home province. (An emergency is an acute, unexpected condition, illness, disease or injury that requires immediate assistance.)

If you or a dependent are hospitalized during this period, in-patient services are covered for 90 days. This 90-day limit will be extended if transporting the patient back to Canada would be a risk to their life.

Some of the emergency expenses covered in this category include a semi-private hospital room; other hospital services provided outside of Canada; out-patient services in a hospital; the services of a doctor.

Emergency Travel Assistance Referral Service (Medi-Passport) supplements your emergency coverage and may arrange for such services as: referrals to physicians, pharmacists and medical facilities; transportation home or to a different medical facility; travel expenses if stranded by a medical emergency; repatriation; assistance with lost luggage or documents.

What the Plan Does Not Cover

The plan will not cover emergency medical services after 365 days have passed since you left your home province.

Charges for pre-existing conditions requiring continuous or routine medical care while outside your home province and injury or illness resulting from hostile action of any armed forces or participating in a riot will not be covered.

Claims

For more information on how to submit a UBC Extended Health claim, visit the Claims section of the UBC Benefits website.