Co-insurance

The way the cost of a service is shared between you and your plan. It exists in addition to any deductibles. So, for example, an 80% co-insurance means that after the deductible has been satisfied, your plan will cover up to 80% of the bill and you would pay the rest.

 

Co-payment

The fixed amount that you must pay towards the cost of a service each time you use your plan. Most often, co-payments exist in situations where a claim is settled at point of sale. For instance, you might see a drug benefit with a $2.00 co-pay amount. Regardless of the cost of the prescription being filled, you are requested to pay $2.00.

 

Dependent 

Your Spouse or Child who is insured under the Provincial Plan.

Spouse

Your legal spouse or a person continuously living with you in a role like that of a marriage partner

Child

Your natural or adopted child or stepchild who is:

Unmarried

Under the age stated below:

For Dental Coverage: Under 21 or under 25 if a full-time student;

For Extended Health Care Coverage: Under 21 or under 25 if a full-time student

Not employed on a full-time basis

Not eligible for insurance as an employee under this or any other Group Benefit Program

 

A child who is incapacitated on the date he or she reaches the age when insurance would normally terminate will continue to be an eligible dependent. However, the child must have been insured under this Benefit Program immediately prior to that date.

 

A child is considered incapacitated if he or she is incapable of engaging in any substantially gainful activity and is dependent on the employee for support, maintenance and care, due to a mental or physical disability. Manulife Financial may require written proof of the child's condition as often as may reasonably be necessary.

 

A stepchild must be living with you to be eligible.

 

Drugs

Must be prescribed in writing by a physician, dentist or other health care professional whose scope of practice within their province permits them to write a prescription;

 

Must be dispensed by a licensed pharmacist;

 

Must have been approved for use by Health Canada and have a drug identification number (DIN)

 

RAMQ - Drug Benefit and Pharmacy Services for Persons Who Reside in Quebec

If you and your dependents reside in Quebec, the following provisions apply to your drug benefit coverage:

 

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

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Covered pharmacy services that are to be paid when the drug is on the RAMQ List; and 

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Drugs that are listed as a covered expense under your drug plan but are not on the RAMQ List.

 

The following provisions apply to the coverage of drugs that are on the RAMQ List and pharmacy services for private plans, as legislated by An Act Respecting Prescription Drug Insurance and the Health Insurance Act (R.S.Q. c., A-29-01). Coverage for all other drugs will be subject to the regular provisions included in your benefit plan.
 

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:

 

i) 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 legislation.

 

ii) For any Legislated pharmacy services which are not otherwise covered under the terms of the Policy, the percentage is as set out by the then applicable Legislation.

 

iii) For any drug on the RAMQ List which is covered under the terms of this benefit, the percentage payable is the greater of:

the benefit percentage stated under the benefit; or

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 a portion of covered drug expenses or covered pharmacy services 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:

 

i) deductible amounts, and

 

ii) 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%; and

 

iii) covered pharmacy services that are performed by pharmacists for drugs on the RAMQ formulary.

 

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 and covered pharmacy services relating to a drug on the RAMQ formulary 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 and covered pharmacy services 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) will not apply to drugs on the RAMQ List or covered pharmacy services. Drug and pharmacy service coverage provided after the lifetime maximum stated under this plan is reached is subject to the following conditions:

 

i) only drugs that are on the RAMQ List are covered, and

ii) covered pharmacy services that are performed for drugs on the RAMQ List, and

iii) the percentage payable by Manulife Financial for covered expenses is the percentage as set out by legislation.

 

f) Termination Age for Covered Drug and Pharmacy Service Expenses
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 Benefit is subject to the following conditions:

i) only drugs that are on the RAMQ List are covered,

ii) only covered pharmacy services related to a drug on the RAMQ List,

iii) the percentage payable by Manulife Financial for covered expenses is the percentage as stipulated in the legislation

iv) the Annual Out-of-Pocket Maximum is as stipulated in the legislation

 

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 your Benefit Booklet.

 

Due Diligence
A process employed by Manulife Financial to assess new drugs, existing drugs with new indications, services or supplies to determine eligibility under the plan. This process may use pharmacoeconomics, cost effectiveness analysis reference information from existing Federal or Provincial formularies, recognized clinical practice guidelines, or an advisory body.

 

Earnings

Earnings are your regular rate of pay from your employer (prior to deductions)
 

including regular bonuses
 

including regular overtime pay
 

Earnings may include other income as agreed to in writing by your employer and Manulife Financial.

For the purposes of determining the amount of your benefit at the time of claim, your earnings will be the lesser of:
 

the amount reported on your claim form, or
 

the amount reported by your employer to Manulife Financial and for which premiums have been paid.
 

Experimental or Investigational
Not approved as an effective, appropriate and essential treatment of an illness or injury.
 

Interchangeable Drug

Includes but is not limited to:

a generic equivalent to the brand name drug deemed to be interchangeable by law where the drug is dispensed;

 

a drug that contains the same active ingredient that has not been deemed interchangeable in the province where the drug is dispensed; but has been identified as interchangeable by Manulife Financial.

 

Lower Cost Alternative

If two or more drugs, supplies or services result in therapeutically similar results, or prescribing guidelines recommend alternate drugs, supplies or services be tried first that are lower in cost, the lower cost alternative will be considered.

 

Medical and Non-Medical Travel Emergencies

Sudden, unexpected injuries which occur or unforeseen illnesses which begin while travelling out-of-province or out-of-Canada for business or pleasure and for accidents or illnesses that were not previously diagnosed or treated in Canada.

 

Medically Necessary

Accepted and recognized by the Canadian medical profession and Manulife Financial as effective, appropriate and essential treatment of a phase of an illness or injury. Manulife Financial has the right after due diligence has been completed to determine whether the drug, service, or supply is eligible under the Plan.

 

Non-Evidence Limit
The amount of insurance benefits you can receive without needing to provide proof of good health. Anything over this figure means that Manulife must review medical evidence before you are approved for the higher amount.

 

Out-Of-Pocket Maximum
This is the maximum amount of money you will have to pay on your own before your insurance benefits begin to take over and pay. It includes things like deductibles, and co-insurance, but not things like co-payments or your monthly premium.

 

Prior Authorization
A claims management feature applied to a specific list of drugs, supplies or services to determine eligibility based on predefined clinical criteria and a pharmacoeconomic or cost effectiveness evaluation.