Prescription drug benefits, up to the amount shown in the Schedule of Health Benefits, that:
- a) are prescribed by a legally qualified medical practitioner or dental practitioner as permitted by law; and
- b) legally require a prescription and has a Drug Identification Number (DIN); and
- c) are approved under GSC’s drug review process; and
- d) are paid on a Pay Direct basis.
GSC reserves the right to manage its drug formularies through an evidence-based review process in which drugs are evaluated based on overall value taking into account clinical efficacy, safety, unmet need and plan affordability. Formulary management includes the right to:
- add a drug to GSC’s formularies;
- exclude or remove a drug from GSC’s formularies regardless of Health Canada approval and/or the existence of provincial coverage;
- place restrictions on a formulary drug as determined by GSC. Restrictions may include, but are not limited to, GSC’s pre-approval of the drug before the claim can be reimbursed, requirement to obtain the drug through an approved provider, and requirement to obtain a lower cost alternative of the same treatment such as a generic or a biosimilar drug.
If approved by GSC, this plan includes drugs with a Drug Identification Number (DIN) that do not legally require a prescription, including but not limited to nitroglycerin, insulin and all other approved injectables, as well as related supplies such as diabetic syringes, needles and testing agents, some limited access drugs and some over-the-counter drugs. In addition, this plan includes all vaccines.
Certain drugs require prior approval from GSC before your drug claim can be reimbursed. Further, certain drugs defined by GSC as specialty, high cost drugs may be required to be purchased from an approved pharmacy that is a member of GSC’s Specialty Drug Preferred Provider Network (PPN) before your claim can be reimbursed. You can find out if your drug requires prior approval or is included in the PPN either by using the online drug search tool available to you through GSC’s Plan Member Online Services, or by contacting GSC’s Customer Service Centre.
Maintenance drugs required to treat lifelong chronic conditions may be required to be purchased in a 90-day supply of a prescription at any one time. Non-maintenance drugs may be purchased in a supply not exceeding 3-months (90-day) supply of a prescription at any one time. However, for all drugs, 6 months for a vacation supply may be purchased and not more than a 13-month supply in any 12 consecutive months.
Generic drug substitution
Reimbursement will be made for the cost of the lowest priced equivalent drug based on specific provincial regulations, unless your medical or dental practitioner has written that there is to be no substitution of the prescribed drug or medicine.
Drug Benefit over age 65: The Drug Benefit co-pay and the deductible (where applicable) in your province of residence are eligible benefits.
Quebec residents only: Legislation requires Green Shield to follow the RAMQ (The Regie de l’assurance maladie du Quebec) reimbursement guidelines for all residents of Quebec. If you are younger than age 65, you must enroll for the Green Shield Prescription Drugs benefit plan and Green Shield will be the only payer. If you are age 65 or older, enrollment in RAMQ is automatic, enrollment in the Green Shield Prescription Drugs benefit plan is optional, and RAMQ would be first payer.
If any provisions of this plan do not meet the minimum requirements of the RAMQ plan, adjustments are automatically made to meet RAMQ requirements.
Eligible benefits do not include and no amount will be paid for:
- a) Reference biologic drugs that have an approved biosimilar;
- b) Vitamins that do not legally require a prescription;
- c) Products which may lawfully be sold or offered for sale other than through retail pharmacies, and which are not normally considered by practitioners as medicines for which a prescription is necessary or required;
- d) Ingredients or products which have not been approved by Health Canada for the treatment of a medical condition or disease and are deemed to be experimental in nature and/or may be in the testing stage;
- e) Mixtures, compounded by a pharmacist, that do not conform to Green Shield’s current Compound Policy.
Extended Health Services
1. Hospital Accommodation: Reimbursement, as shown in the Schedule of Health Benefits, of reasonable and customary charges in the area where received, for accommodation in a public general hospital, or a convalescent or rehabilitation hospital or a convalescent or rehabilitation wing in a public general hospital, or a public chronic hospital or chronic care in a public general hospital, provided your provincial health insurance plan has accepted or agreed to pay the ward or standard rate.
2. Hearing Care: Reimbursement for hearing aids, repairs or replacement parts, if recommended or approved by the attending legally qualified medical practitioner, up to the amount shown in the Schedule of Health Benefits. No amount will be paid for replacement batteries.
3. Medical Items and Services: Reimbursement for reasonable and customary charges, up to the amount, where applicable, as shown in the Schedule of Health Benefits for:
- a) Aids for daily living: such as hospital style beds, including rails and mattresses; bedpans; standard commodes; decubitus (bedridden) supplies, I.V. stands; portable patient lifts (including batteries); trapezes; and urinals;
- b) Footwear’ when prescribed by your attending physician, nurse practitioner, podiatrist or chiropodist and dispensed by your podiatrist, chiropodist, chiropractor, orthotist, or pedorthist:
- i) custom made foot orthotics or adjustment to custom made foot orthotics;
- ii) custom made boots or shoes, and adjustments to orthopedic shoes;
- c) Braces, casts;
- d) Diabetic equipment, such as blood glucose monitors and lancets;
- e) Medical services, such as diagnostic tests, X-rays and laboratory tests;
- f) Incontinence/Ostomy equipment, such as catheter supplies and ostomy supplies;
- g) Mobility aids, such as canes, crutches, walkers and wheelchairs (including wheelchair batteries);
- h) Standard prosthetics, such as an arm, hand, leg, foot, breast, eye and larynx;
- i) Respiratory/Cardiology equipment, such as compressors, inhalant devices, tracheotomy supplies and oxygen;
- j) Compression stockings;
- k) Wigs, for temporary or permanent hair loss due to of a chemotherapy or radiation treatment, and alopecia.
- Some items may require pre-authorization. To confirm eligibility prior to purchasing or renting equipment, submit a Pre-Authorization Form to Green Shield.
- a) The rental price of durable medical equipment will not exceed the purchase price. Green Shield’s decision to purchase or rent will be based on the physician’s estimate of the duration of need as established by the original prescription. Rental authorization may be granted for the prescribed duration. Equipment that has been refurbished by the supplier for resale is not an eligible benefit;
- b) Durable medical equipment must be appropriate for use in the home, able to withstand repeated use and generally not useful in the absence of illness or injury;
- c) When deluxe medical equipment is a covered benefit, reimbursement will be made only when deluxe features are required in order for the covered person to effectively operate the equipment. Items that are not primarily medical in nature or that are for comfort and convenience are not eligible.
4. Emergency Transportation: Reimbursement for professional land or air ambulance to the nearest hospital equipped to provide the required treatment, when medically required as the result of an injury, illness or acute physical disability, up to the amount shown in the Schedule of Health Benefits.
5. Private Duty Nursing in the Home: Reimbursement for the services of a Registered Nurse (R.N.) in the home on a visit or shift basis, up to the amount shown in the Schedule of Health Benefits. No amount will be paid for services which are custodial and/or services which do not require the skill level of a Registered Nurse (R.N.).
A Pre-Authorization Form for Private Duty Nursing must be completed by the attending physician and submitted to Green Shield.
6. Paramedical Services: Reimbursement for the services of the practitioners included, up to the amount shown in theSchedule of Health Benefits, when the practitioner rendering the service is licensed by their provincial regulatory agency or a registered member of a professional association and that association is recognized by Green Shield. Please contact the Green Shield Customer Service Centre to confirm practitioner eligibility.
7. Accidental Dental: Reimbursement for the services of a licensed dental practitioner for dental care when necessitated by a direct blow to the mouth and not by an object wittingly or unwittingly placed in the mouth. The accident must occur to natural teeth while the coverage is in force. When natural teeth have been damaged eligible services are limited to one set of artificial teeth. You must notify Green Shield immediately following the accident and the treatment must commence within 180 days of the accident.
Green Shield will not be liable for any services performed after the earlier of a) 365 days following the accident, or b) the date you or your dependent cease to be covered under this plan.
No amount will be paid for periodontia or orthodontia treatments or the repair or replacement of artificial teeth.
Charges will be based on the current Provincial Dental Association Fee Guide for General Practitioners in the province where services are rendered. Approval will be based on the current status and/or benefit level of the covered person at the time that we are notified of the accident. Any change in coverage will alter Green Shield’s liability.
In the event of a dental accident, claims should be submitted under the health benefit plan before submitting them under the dental plan.
For an accident involving a young dependent child, and for whom permanent treatment must be delayed due to the age of the child, treatment must be completed prior to the age limit shown for an unmarried child under the definition of Dependent, point c).
Eligible benefits do not include and reimbursement will not be made for:
1. Services or supplies received as a result of disease, illness or injury due to:
- a) intentionally self-inflicted injury while sane or insane;
- b) an act of war, declared or undeclared;
- c) participation in a riot or civil commotion; or
- d) committing a criminal offence;
2. Services or supplies provided while serving in the armed forces of any country;
3. Failure to keep a scheduled appointment with a legally qualified medical or dental practitioner;
4. The completion of any claim forms and/or insurance reports;
5. Any form of medical cannabis for the treatment of any medical condition, regardless of whether it is authorized by way of a medical document or prescription from a legally-authorized medical practitioner and obtained from a Health Canada-licensed producer pursuant to any federal or provincial legislation or regulation regarding access to and/or distribution of medical cannabis;
6. Any specific treatment or drug which:
- a) does not meet accepted standards of medical, dental or ophthalmic practice, including charges for services or supplies which are experimental in nature;
- b) is not considered to be effective (either medically or from a cost perspective) as determined by GSC’s drug review process regardless if Health Canada’s approved the drug;
- c) is an adjunctive drug prescribed in connection with any treatment or drug that is not an eligible service;
- d) is administered in a hospital or is required to be administered in a hospital in accordance with Health Canada’s approved indication for use;
- e) is not dispensed by the pharmacist in accordance with the payment method shown under the Prescription Drugs benefit;
- f) is not being used and/or administered in accordance with Health Canada’s approved indication for use (i.e., off-label use), even though such drug or procedure may customarily be used in the treatment of other illnesses or injuries;
7. Services or supplies that:
- a) are not recommended, provided by or approved by the attending legally qualified (in the opinion of Green Shield) medical practitioner or dental practitioner as permitted by law;
- b) are legally prohibited by the government from coverage;
- c) you are not obligated to pay for or for which no charge would be made in the absence of benefit coverage or for which payment is made on your behalf by a not-for-profit prepayment association, insurance carrier, third party administrator, like agency or a party other than Green Shield, your plan sponsor or you;
- d) are provided by a health practitioner whose license by the relevant provincial regulatory and/or professional association has been suspended or revoked;
- e) are not provided by a designated provider of service in response to a prescription issued by a legally qualified health practitioner;
- f) are used solely for recreational or sporting activities and which are not medically necessary for regular activities;
- g) are primarily for cosmetic or aesthetic purposes, or are to correct congenital malformations;
- h) are provided by an immediate family member related to you by birth, adoption, or by marriage and/or a practitioner who normally resides in your home. An immediate family member includes a parent, spouse, child or sibling;
- i) are provided by your plan sponsor and/or a practitioner employed by your plan sponsor, other than as part of an employee assistance plan;
- j) are a replacement of lost, missing or stolen items, or items that are damaged due to negligence. Replacements are eligible when required due to natural wear, growth or relevant change in your medical condition but only when the equipment/prostheses cannot be adjusted or repaired at a lesser cost and the item is still medically required;
- k) are video instructional kits, informational manuals or pamphlets;
- l) are for medical or surgical audio and visual treatment;
- m) are special or unusual procedures such as, but not limited to, orthoptics, vision training, subnormal vision aids and aniseikonic lenses;
- n) are delivery and transportation charges;
- o) are for Insulin pumps and supplies (unless otherwise covered under the plan);
- p) are for medical examinations, audiometric examinations or hearing aid evaluation tests;
- q) are batteries, unless specifically included as an eligible benefit;
- r) are a duplicate prosthetic device or appliance;
- s) are from any governmental agency which are obtained without cost by compliance with laws or regulations enacted by a federal, provincial, municipal or other governmental body;
- t) would normally be paid through any provincial health insurance plan, Workplace Safety and Insurance Board or tribunal, the Assistive Devices Program or any other government agency, or which would have been payable under such a plan had proper application for coverage been made, or had proper and timely claims submission been made;
- u) were previously provided or paid for by any governmental body or agency, but which have been modified, suspended or discontinued as a result of changes in provincial health plan legislation or de-listing of any provincial health plan services or supplies;
- v) may include but are not limited to, drugs, laboratory services, diagnostic testing or any other service which is provided by and/or administered in any public or private health care clinic or like facility, medical practitioner’s office or residence, where the treatment or drug does not meet the accepted standards or is not considered to be effective (either medically or from a cost perspective, based on Health Canada’s approved indication for use);
- w) are provided by a medical practitioner who has opted out of any provincial health insurance plan and the provincial health insurance plan would have otherwise paid for such eligible service;
- x) relates to treatment of injuries arising from a motor vehicle accident;Note: Payment of benefits for claims relating to automobile accidents for which coverage is available under a motor vehicle liability policy providing no-fault benefits will be considered only if–
- i) the service or supplies being claimed is not eligible; or
- ii) the financial commitment is complete;
A letter from your automobile insurance carrier will be required;
- y) are cognitive or administrative services or other fees charged by a provider of service for services other than those directly relating to the delivery of the service or supply.
Reimbursement for the services performed by a licensed Optometrist, Optician or Ophthalmologist, up to the amounts shown in the Schedule of Health Benefits, for:
- a) prescription eyeglasses or contact lenses;
- b) medically necessary contact lenses when visual acuity cannot otherwise be corrected to at least 20/40 in the better eye or when medically necessary due to keratoconus, irregular astigmatism, irregular corneal curvature or physical deformity resulting in an inability to wear normal frames;
- c) replacement parts for prescription eyeglasses; or
- d) the services of a licenced optometrist, when such services are not covered by the provincial health insurance plan:
- e) Optometric eye examinations for visual acuity performed by a licensed optometrist, ophthalmologist or physician limited to one exam in a 24 month period (available only in those provinces where eye examinations are not covered by the provincial health insurance plan);
Eligible benefits do not include and no amount will be paid for:
- a) Prescription industrial safety eyeglasses;
- b) Medical or surgical treatment;
- c) Special or unusual procedures such as, but not limited to, orthoptics, vision training, subnormal vision aids and aniseikonic lenses;
- d) Follow-up visits associated with the dispensing and fitting of contact lenses; or
- e) Charges for eyeglass cases.