Prescription drug benefits, up to the amount shown in the Schedule of Benefits, that:
- a) are prescribed by a legally qualified medical practitioner or dental practitioner as permitted by law;
- b) legally require a prescription and have a Drug Identification Number; and
c) are paid on a Pay Direct basis.
If approved by GSC, this plan includes drugs with a Drug Identification Number (DIN) that do not legally require a prescription, including 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 may require prior approval. Your Pharmacist is aware of the drugs that fall into this category.Maintenance drugs required to treat lifelong chronic conditions must 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 not eligible benefits.
Quebec residents only: Legislation requires GSC 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 GSC Prescription Drugs benefit plan and GSC will be the only payer. If you are age 65 or older, enrollment in RAMQ is automatic, enrollment in the GSC 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 the following, and no amount will be paid for:
Extended Health Services
1. Hospital Accommodation: Reimbursement, as shown in the Schedule of Benefits, of reasonable and customary charges in the area where received, for accommodation in a public general hospital, provided your provincial health insurance plan has accepted or agreed to pay the ward or standard rate.
2. Medical Items and Services: When prescribed by a legally qualified medical practitioner unless specified otherwise below, reimbursement for reasonable and customary charges for:
- a) Aids for daily living: such as hospital style beds, including rails and mattresses; bedpans; standard commodes; decubitus (bedridden) supplies; IV stands; portable patient lifts (including batteries); trapezes; 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 adjustments to custom made foot orthotics;
- ii) custom-made boots or shoes, adjustments to orthopedic shoes, or footwear as an integral part of a brace, (subject to a medical pre-authorization);
- c) Braces, casts;
- d) Incontinence/Ostomy equipment, such as catheter supplies and ostomy supplies;
- e) Mobility aids, such as canes, crutches, walkers and wheelchairs;
- f) Standard prosthetics, such as an arm, hand, leg, foot, breast, eye and larynx;
- g) Respiratory/Cardiology equipment, such as compressors, inhalant devices, tracheotomy supplies and oxygen;
- h) Compression stockings;
- i) Medical services, such as diagnostic tests, x-rays and laboratory tests;
- j) Diabetic equipment, such as blood glucose monitors and lancets.
- 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 legally qualified medical practitioner’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;
3. 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 Benefits.
4. Paramedical Services: Reimbursement for the services of the practitioners included, up to the amount shown in the Schedule of 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 GSC. Please contact the GSC Customer Service Centre to confirm practitioner eligibility.
- Podiatry services are not eligible until your provincial health insurance plan annual maximum has been exhausted.
5. Accidental Dental: Reimbursement for the services of a licensed dental practitioner for dental care to natural teeth 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 GSC immediately following the accident and the treatment must commence within 180 days of the accident.
GSC 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 GSC’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.
6. Vision: Reimbursement for the services performed by a licensed Optometrist, Optician or Ophthalmologist, up to the amounts shown in the Schedule of Benefits:
Eligible benefits do not include and no amount will be paid for:
- a) Medical or surgical treatment;
- b) Special or unusual procedures such as, but not limited to, orthoptics, vision training, subnormal vision aids and aniseikonic lenses;
- c) Follow-up visits associated with the dispensing and fitting of contact lenses;
- d) Charges for eyeglass cases.
Eligible benefits do not include and reimbursement will not be made for:
- a) an act of war, declared or undeclared;
- b) participation in a riot or civil commotion; or
- c) committing a criminal offence;
- a) are not recommended, provided by or approved by the attending legally qualified (in the opinion of GSC) 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 GSC, 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;
- ) 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 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 out of 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.