CUPE 116

Your Extended Health Plan helps cover the cost of medically necessary expenses for prescription drugs, the services of many health-care professionals, prescription eyewear, medical equipment and services, and other health-care expenses that are not covered by BC’s Medical Services Plan (MSP).

For complete details, please refer to your Sun Life booklet.

Annual deductible

Your deductible is $25 each benefit year (January 1 – December 31) for each person enrolled in your Extended Health Plan, up to a maximum of $25 per family.

Reimbursement level for eligible expenses

After you have paid your annual deductible, you will be reimbursed based on the reasonable and customary charge for the item or service at the following levels, up to your lifetime maximum of $2,000,000 per person:

* You will be reimbursed for 70% to 85% of the cost of the eligible expenses of each person enrolled in your plan until that person has reached $1,000 in reimbursable expenses for prescription drugs, paramedical services, medical services and equipment, and in-province hospital costs combined. After this, you will then be reimbursed for 100% of that person’s eligible expenses for the remainder of the benefit year.

Prescription drugs

To ensure your prescription drug costs are covered, please confirm that you are registered with Fair PharmaCare. Learn more about Fair PharmaCare.

What the plan covers

You will generally be reimbursed for 85% of the costs of eligible prescription drugs that are prescribed by a physician or dentist and obtained from a pharmacist. If the drug is not listed as a BC PharmaCare Formulary drug, you will be reimbursed for 70% of the cost of the drug.

You are also covered for both prescribed and over-the-counter smoking cessation drugs to a maximum of $300 per person per benefit year and vaccinations to a maximum of $300 per person per benefit year.

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

What the plan does not cover

The plan does not cover all drugs or medicines, even when they are prescribed. Some examples of what is not covered include over-the-counter drugs, preventive drugs, the cost of giving injections, vitamins, natural health products, treatments for weight loss if not medically necessary, hair growth stimulants, and erectile dysfunction or fertility drugs.

For more information on prescription drug coverage and what is excluded, please refer to pages 11-13 and 22-24 of the Sun Life booklet.

Catastrophic drug claim appeal policy

UBC has developed guidelines for appointing a claims adjudicator to examine cases and help active faculty and staff members who are facing financial hardship as a result of needing expensive drug therapy for themselves or their eligible dependents for catastrophic illnesses. This policy also seeks to ensure safe, appropriate and effective use 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.

Paramedical services

What the plan covers

You will be reimbursed for 80% or 100% of the cost of the services of some paramedical practitioners. There is a maximum annual amount that you can be reimbursed for each type of service.

The practitioners covered under the plan are:

  • 100% for licensed psychologists, social workers or registered clinical counsellors (up to a maximum of $2,500 for each person per benefit year and includes counselling services and psychological testing);
  • 80% for licensed speech therapists, acupuncturists, chiropractors, naturopaths, homeopaths, podiatrist, chiropodists, osteopaths, dietitians, audiologists or occupational therapists (up to a combined maximum of $600 for each person per benefit year); and
  • 80% for licensed physiotherapists (no doctor referral required) or massage therapists (doctor or midwife referral required), up to a combined maximum of $750 for each person per benefit year.

A doctor or midwife referral is required for massage therapists only.

Paramedical practitioner qualifications

The cost of paramedical services will only be covered if the paramedical practitioner meets specific qualifications/designations for their profession and they are licensed/registered with an appropriate regulatory body or society where the service is received (in Canada or the United States only). For example, in British Columbia, you will only be reimbursed for the cost of the services provided by a Naturopath with an N.D. (Doctor of Naturopathic Medicine) designation and who is licensed/registered with the College of Naturopathic Physicians of British Columbia.

Click here for a complete list of the acceptable qualifications/designations and regulatory bodies and societies for all paramedical practitioners in British Columbia.

Reasonable and customary charges

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

Sun Life will determine “reasonable and customary” charges as the basis for reimbursing your paramedical claims, which are also subject to the reimbursement level and maximum amounts specified under the Extended Health Plan. Sun Life outlines the reasonable and customary charges by paramedical practitioners in each province in the Reasonable & Customary Charges for Paramedical Services document. If your practitioner charges more than this, you are responsible for this additional cost.

What the plan does not cover

The plan does not cover the services of a religious or spiritual healer, kinotherapist, reflexologist, sexologist, sex therapist or shiatsu specialist.

For more information on paramedical coverage and what is excluded, please refer to page 20-21 and 22-24 of the Sun Life booklet.

Vision care

What the plan covers

You will be reimbursed for 100% of the cost of vision care expenses up to a maximum of $400 in a 24-month period for a person under the age of 19 enrolled in your plan or in a 36-month period for any other person enrolled in your plan.

The plan covers:

  • contact lenses or eyeglasses prescribed by a licensed optometrist or ophthalmologist,
  • eye exams,
  • prescription sunglasses, and
  • laser eye correction surgery, when performed by an ophthalmologist.

You can claim the maximum of $400, less the amount of any benefit that has been paid to you during the previous 24 months for a person under the age of 19, or previous 36 months for any other person.

Reasonable and customary charges for eye exams

Sun Life will reimburse “reasonable and customary” charges for eye exams, which are also subject to the reimbursement level and maximum amounts specified under the Extended Health Plan. Sun Life outlines the reasonable and customary charges for an optometrist or ophthalmologist in each province in the Reasonable & Customary Charges for Paramedical Services document. If your practitioner charges more than this, you are responsible for this additional cost.

What the plan does not cover

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

For more information on vision care coverage and what is excluded, please refer to page 21-24 of the Sun Life booklet.

Medical services and equipment

What the plan covers

You will be reimbursed for 80% of the costs of a wide variety of medical services and equipment when ordered by a doctor or dentist.

The plan covers services that include:

  • private duty nursing care in-hospital or out-of-hospital if medically necessary,
  • transportation in a licensed ambulance or air ambulance,
  • custom-made orthopedic shoes and orthotic inserts (doctor’s referral required every 5 years for those with chronic foot conditions),
  • knee braces made of metal or rigid/semi-rigid plastic when prescribed by a doctor,
  • accidental dental services,
  • equipment recommended for therapeutic use, such as wheelchairs, hearing aids, insulin pumps, blood transfusions and dialysis machines, and
  • one pair of contact lenses or intraocular lenses following cataract surgery, if this is not covered by MSP. This is not counted towards your $400 vision care maximum.

What the plan does not cover

The cost of some services and equipment is not covered under the plan, even when a doctor prescribes them. These include:

  • off-the-shelf non-custom-made orthopedic shoes and inserts,
  • knee braces used for athletic purposes,
  • experimental treatments,
  • personal comfort items,
  • services and supplies for cosmetic purposes, and
  • the services of a licensed practical nurse.

If your medical services or equipment cost more than $5,000, you must obtain pre-authorization for these expenses from Sun Life. You may also require a doctor’s referral, and maximum amounts may apply. For more information on coverage and exclusions, please refer to pages 16-20 and 22-24 of the Sun Life booklet.

Emergency out-of-province medical care

What the plan covers

You will be reimbursed for 100% of the costs of out-of-province emergency doctor and hospital services required within 365 days of the date you leave BC. An emergency is an acute, unexpected condition, illness, disease or injury that requires immediate assistance.

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, and
  • the services of a doctor.

If you or a dependent are hospitalized while travelling outside of BC, the cost of in-patient hospital services is covered for 90 days. This 90-day limit will be extended if transporting the patient back home would be a risk to their life.

In addition to emergency doctor and hospital services, emergency expenses for all other services or supplies eligible under this plan are also covered outside of BC (emergency and non-emergency basis) as if you had incurred the expense in BC. For example, emergency prescription drug expenses will be reimbursed as if you had made the drug purchase in BC.

You are also covered for other emergency travel assistance services through Medi-Passport, which is provided by Sun Life’s travel benefit provider, Allianz Global Assistance. These services include:

  • referrals to physicians, pharmacists and medical facilities,
  • transportation home or to a different medical facility,
  • travel expenses if stranded by a medical emergency,
  • repatriation, and
  • assistance with lost luggage or documents.

What the plan does not cover

The plan does not cover the cost of emergency medical services:

  • obtained after 365 days have passed since you left BC;
  • for pre-existing conditions that require continuous or routine medical care while outside your home province (unless the condition was stable and controlled at the time of departure from Canada and your doctor has stated you are cleared to travel);
  • services that are not immediately required or that could reasonably be delayed until you return to BC, unless your medical condition reasonably prevents you from returning to BC before receiving the medical services;
  • services relating to an illness or injury that caused the emergency, after such emergency ends;
  • continuing services, arising directly or indirectly out of the original emergency or any recurrence of it, after the date that Sun Life or Allianz Global Assistance, based on available medical evidence, determines that you can be returned to the province where you live and you refuse to return;
  • services that are required for the same illness or injury for which you received emergency services, including any complications arising out of that illness or injury, if you had unreasonably refused or neglected to receive the recommended medical services;
  • where the trip was taken to obtain medical services for an illness or injury, services related to that illness or injury, including any complications or any emergency arising directly or indirectly out of that illness or injury;
  • illness resulting from the hostile action of any armed forces (military or police), insurrection, riot, civil commotion or terrorist activity that you participated in;
  • any work for which you were compensated that was not done for the employer (UBC) as the provider of this plan; and
  • services for an illness or injury caused by your participation in a criminal offence.

If you are on an unpaid leave and older than 65

If you are on an unpaid leave of absence and over the age of 65, you and your dependents will be reimbursed for the cost of emergency doctor and hospital services and travel assistance services through Medi-Passport obtained within 60 days (and not 365 days) of the date you leave your home province. All other coverage is as described above.

For complete information on your benefits while travelling outside of BC and Canada, visit our Travel benefits section and pages 14-16 and 26-31 of the Sun Life booklet.

In-province hospital

What the plan covers

You will be reimbursed for 80% of the cost difference between a room on a general hospital ward (covered by MSP) and a semi-private or private hospital room. Care in a hospice is reimbursed at 80% ($40/day for a maximum of 60 days).

What the plan does not cover

The plan does not cover:

  • hospital outpatient fees and user fees,
  • care in a nursing home or rest home, and
  • care in an alcohol or drug abuse treatment centre, even if it is located in a hospital.

For more information on in-province hospital or hospice coverage and what is excluded, please refer to page 13-14 and 22-24 of the Sun Life booklet.