The McGill Supplemental Health Plan provides protection for a range of medical items, services and procedures not covered under your provincial plan.
To qualify for coverage under this plan, you and your eligible spouse and children must qualify for provincial health care benefits. Non-Canadian residents and Canadian residents returning to Quebec after 183 days out of the province will be required to apply for Quebec Medicare (RAMQ ) upon arrival in Quebec, and will be subject to a 3-month waiting period for this coverage. For more information about health coverage during this 3-month waiting period please refer to Provincial Plan Replacement Coverage.
This section gives an overview of what is and is not covered by the plan.
What the plan covers
The McGill Supplemental Health Plan covers reasonable and customary charges for semi-private hospital accommodations, prescription drugs, health practitioner services and a range of medical supplies and services not covered under your provincial plan.
What is reasonable and customary?
These are charges, as determined by the insurer, that fall within the usual range of charges for the same or comparable service or supply. The determination takes into account the standing of the practitioner who provides the service and the geographic area in which the charge is incurred. For more detailed information, see the Coverage by area/service section below.
What the plan does not cover
The plan does not pay any benefit or accept liability for claims for the following items or services. This is not an exhaustive list. If you are in doubt as to whether an item or service is covered by the Plan see the Coverage by area/service section below, or/and contact Manulife Financial at 1-800-268-6195.
- Any portion of an eligible expense which is in excess of the reasonable and customary charge for the services or supplies in the locality where the service is provided
- Equipment such as orthopaedic mattresses, exercise equipment, whirlpools, air-conditioning and air purifying units, and any other equipment which the administrator considers to be an ineligible expense
- Expenses for custodial care
- Expenses incurred for psychological disorders, including functional nervous disorders if the expenses are incurred in an institution specializing in the treatment of the disorder or disease in question
- Expenses incurred for transportation other than emergency ambulance (eg. to and from doctor visits, physiotherapy treatment, outpatient hospital treatments).
- Expenses for services rendered by a naturopath, massage therapist, podiatrist, audiologist, psychotherapist, conjugal and family therapist, counselor or any other therapist who is not a licensed psychologist or licensed social worker.
- Eyeglasses, contact lenses, laser eye surgery and expenses of an opthalmologist for services other than the actual eye exam
- Hospital expenses incurred while travelling outside the country (other than for referrals or emergency treatment)
- Medical expenses arising, directly or indirectly, from:
- war, insurrection or the hostile action of the armed forces of any country (except Employee Travel Assistance)
- participation in a riot, civil commotion, or commission of a criminal offence
- any cause for which benefits or compensation is provided under any workers' compensation law or similar legislation
- Rest cure or travel for reasons of health
- Services or supplies that are paid for under provisions of any government-sponsored plan or program
- Treatment, surgery, care, service, examination or appliance, which is:
- not medically necessary
- given or required for cosmetic purposes, except for dental treatment required as a result of an accident
- given or required for reasons other than curative
- plastic surgery
- given or required in relation to an operation or treatment of an experimental nature, or
- in excess of what is ordinarily given or required in accordance with current therapeutic practice
- Treatment or appliance (related directly or indirectly to full mouth reconstruction) to correct vertical dimension and temporomandibular joint dysfunction.
- Charges of an ophthalmologist for services other than the actual eye exam (eg. eye drops)
- Charges for a brand name drug when a generic equivalent exists. The generic equivalent will be reimbursed
- Doctors fees: including (but not limited to) private doctor visits; fees to administer medication, fees to perform a medical procedure (other than those covered under the Out-of-country/province – Emergency travel Assistance benefit)
- Stays in long term care facilities
- The cost of giving injections, serums or vaccines
- Diagnostic tests performed in a doctor's office or a pharmacy, diagnostic tests performed by an audiologist, charges for the drawing of blood or charges incurred for transportation of blood for analysis.
Semi-private hospital (in Canada)
The plan covers 100% of the difference between the regular ward rate reimbursed through the provincial plan and the semi-private room rate charged by a licensed hospital. This includes hospital out-patient services.
For information on chronic, convalescent and rehabilitative hospitals, see "Supplies and services" below.
Prescription drugs (80%)
The plan covers drugs or medicines required for therapy provided that they are prescribed in writing by a doctor (or dentist where appropriate), require the written prescription of a physician (or dentist) by law and convention, and are dispensed by a licensed pharmacist.
**(For plan members 65+: Please refer to Turning 65 for information about changes to drug coverage under the McGill Supplemental Health Plan).
If a generic equivalent exists for a brand name drug, the cost of the lowest generic equivalent will be reimbursed at 80%.
The amount applied towards your annual out-of-pocket maximum is based on the reimbursement of the cost of the generic. Once your annual 'out-of-pocket maximum' is reached, reimbursement of brand-name drugs without 'no-substitution' prescriptions will still be reimbursed based on the cost of the generic.
Example of costs and reimbursements for a generic vs a brand name drug
Below is an example using the costs of the brand name drug, Lipitor, and its generic equivalent, showing the amounts reimbursed by the Health Plan, and the plan member’s out-of-pocket expense for each drug - effective January 1, 2016.
|Drug Lipitor||Cost*||Percentage reimbursed by Health Plan||Dollar amount reimbursed by Health Plan||Amount paid by member||Amount applied to out-of-pocket maximum|
|Generic drug (10 mg x 90 pills)||$28.24||80%||$22.59||$5.65||$5.65|
|Brand name (10 mg x 90 pills)||$155.69||80% of generic||$22.59||$133.10||$5.65|
|Brand name - No substitution prescription (10 mg x 90 pills)||$155.69||80%||$124.55||$31.14||$31.14|
*This refers to the ingredient cost only; the dispensing fee and pharmacist’s markup would be in addition. The costs indicated were obtained from the RAMQ website.
New Pharmacist Services
Quebec pharmacists can now provide several new professional services to their patients, of which the McGill Health Plan is required to reimburse the following four services:
- Prescribing medication for the treatment of certain minor ailments/conditions when the diagnosis and treatment are known
- Prescribing a medication when no diagnosis is required
- Adjusting a prescription
- Extending a prescription
Charges for these new services will be reimbursed under the Health Plan in accordance with the percentage covered by the Régie de l'assurance maladie du Québec (RAMQ Drug Plan).
- Drugs for the treatment of infertility up to a lifetime maximum of $2,400 for each person
- Insulin, including needles, syringes, reagent strips, cotton and alcohol swabs for the treatment of diabetes
- Life-sustaining drugs
- Oral contraceptives
- Vaccines and compound serums that require a prescription
- Anti-obesity drug Xenical up to a lifetime maximum of $2,400
- Stop-smoking products covered by the RAMQ and only when obtained with a written prescription from a physician, pharmacist or nurse. These will be reimbursed at the RAMQ's reimbursement level and are subject to coverage limits (duration and quantity). Covered products include: skin patches, nicotine gum and lozenges, 2 types of tablets. For more information visit the RAMQ website.
Drugs not covered:
The following are not covered by the McGill Supplemental Health Plan unless they are included under the RAMQ current drug formulary; in which case, they will be reimbursed according to the RAMQ’s reimbursement level. Please refer to RAMQ's page on prescription drugs they cover for more information.
- Anti-obesity treatments, other than Xenical
- Anti-impotence treatments
- Stop-smoking products
- Baby foods and formula
- Cough medicines
- Dietary food supplements, minerals, proteins, vitamins and collagen treatments
- Hair growth stimulants
- Medicines obtained directly from a doctor or dentist
- Patent or proprietary medicines you can obtain without a prescription, including over-the-counter drugs
- Drugs dispensed and distributed through prescription on-line sites (Internet pharmacies)
Health practitioners (80%)
The plan covers the following services when REFERRED BY A DOCTOR, subject to the outlined limits and restrictions:
- Private duty nursing (80%)
- Up to $30,000 during any consecutive 60-month period for nursing care performed at the patient's residence.
- The service must be authorized, in writing, by the attending physician.
- Services that are for custodial care, eg. personal hygiene, meal preparation, help with mobility, are not covered.
- Nursing services must be provided by a Registered Nurse, Registered Nursing Assistant or Registered Trained Attendant who is not related to or living with the patient.
- You must submit a Pre-Determination form to the insurer before the nursing services can begin.
For details, please refer to the Submitting Claims section of this website.
The plan also covers the following services of the following practitioners WITHOUT A DOCTOR'S REFERRAL. ALL services must be provided by a licenced practitioner who is a member of an accredited association or order:
- Psychological services: 80% of eligible expenses up to an annual maximum of $1,000 per person each benefit year for the services of a licensed psychologist, or a licensed social worker who is a member of the Order of Social Workers.
- Physiotherapy, occupational therapy, athletic therapy, or speech therapy: 80% of expenses for services performed by a licensed physiotherapist, licensed occupational therapist, licensed certified athletic therapist, or licensed speech therapist up to a combined maximum of $750 per person each benefit year.
- Chiropractors, osteopaths*, acupuncturists, or dieticians: 80% of expenses for services performed by a licensed chiropractor, licensed osteopath*, licensed acupuncturist, licensed dietician to a combined maximum of $300 per person each benefit year. This includes one x-ray per benefit year by each licensed practitioner.
*Effective September 15, 2017, Manulife no longer recognizes services by osteopath providers registered with certain associations. Refer to pm_osteopath_july_2017_en.pdf
- Psychoanalysis: up to $15 per visit for psychoanalytic treatment at home or office. This treatment must be provided by a member of the Canadian Psychoanalytic Society or similar society outside of Canada.
Supplies and services (75%)
The plan covers the following medical supplies and services when prescribed by an appropriate medical practitioner (subject to the outlined limits and restrictions) - unless otherwise indicated, reimbursement is at 75%.
- Accidental dental: charges for dental treatment required to repair natural teeth damaged by an external, sudden and violent blow to the mouth. These services must be provided within six months of the date of the accident. Reimbursements will be limited to the current fee guide for dental services provided by general practitioners published by the Quebec Dental Surgeons Association.
- Ambulance services: charges for licensed emergency ambulance services required to transport a stretcher patient to and from the nearest licensed hospital able to provide essential care. This includes charges for licensed air transport to the nearest licensed hospital for necessary emergency care.
- Artificial limbs and eyes: including necessary replacements (does not include myoelectric appliances).
- Casts, splints, trusses and braces
- Convalescent and rehabilitative hospitals: the plan covers the cost of the semi-private room charge for a stay in a chronic, convalescent or rehabilitative hospital, provided the stay is:
- Ordered by a doctor;
- Begins within 14 days of leaving a licensed hospital;
- Is primarily for rehabilitative treatment (rather than custodial care).
This coverage is limited to 120 days per disability.
- Colostomy and ileostomy supplies: charges for essential colostomy and ileostomy supplies.
- Diabetic supplies and equipment:
- Needles, syringes, reagent strips, cotton and alcohol swabs for the treatment of diabetes.
- One insulin pump every 5 years, prescribed in writing by a medical doctor.
- Insulin pump supplies as needed.
- Diagnostic Services: when carried out in a private laboratory or clinic in the province of Quebec that is, in the insurer’s opinion, qualified to provide the required services. Covered services include, but are not limited to, the following: laboratory tests, x-ray examinations, ultrasound and MRIs. These services are covered up to a maximum of $750 per person, per benefit year. The following are not covered: tests performed in a doctor's office or a pharmacy, diagnostic services performed by an audiologist, and charges for the drawing of blood.
- Durable medical equipment: the rental (or purchase when approved by the insurer) of manual hospital beds, respiratory and oxygen equipment, and other durable equipment usually found only in hospitals. The purchase of one insulin pump per lifetime of the insured and related medical supplies.
- Intra-ocular lens: required as a result of cataract surgery to a limit of one lens per eye during the lifetime of the insured.
- Elastic support stockings: up to $50 per person each benefit year.
- Eye Exams: 100% of the cost of an eye exam rendered by a licensed optometrist or an ophthalmologist registered under Medicare limited to a maximum of $70 once every 24 consecutive months. Please refer to the Submitting Claims section on this website for specific requirements for claims payment.
- Glucometers: up to $200 per person every 36 consecutive months when prescribed in writing by a medical doctor.
- Hearing aids: up to $500 per person in any five consecutive years. The aid must be prescribed in writing by an otolaryngologist. The plan does not cover batteries and professional services.
- Mammary prostheses: required as the result of surgery, to a limit of two prostheses per person each benefit year. The maximum cost for each prosthesis is limited to $200.
- Mobility equipment: the rental or purchase (when approved by the insurer) of crutches, canes, walkers and non-motorized wheelchairs.
- Orthotic inserts for shoes or orthopaedic shoes: up to one custom-made pair per person each benefit year. The devices must be made in a specialized orthopaedic laboratory and must be prescribed by a physician, podiatrist or chiropodist. As well, orthotics and orthopedic shoes must be dispensed by an Orthotist, Pedorthist, Podiatrist or Chiropodist. Please refer to the 'Making a Claim' section on this site for specific requirements for claims payment.
- Oxygen, plasma and blood transfusions.
- Radiotherapy or coagulotherapy services.
- Wigs and hairpieces: for patients with temporary hair loss resulting from chemotherapy, up to a lifetime maximum of $200 per person.
Out-of-province medical services (100%)
Emergency Travel Assistance
For important coverage details, refer to the Emergency Travel Assistance section on this website.
Unstable political and environmental conditions in some countries may affect availability of emergency medical or assistance services. For more info on travel conditions, consult Travel Advice and Advisories published by the Consular Affairs Bureau, Federal Dept of Foreign Affairs.
The plan covers the following benefits for charges incurred for care unavailable in Canada, when referred to by a licensed doctor (M.D.) and approved in advance by the provincial health plan and the insurer, but not beyond 60 days, and provided part of the charge is payable under the provincial health plan of the province of residence:
- Charges in excess of the ward rate under the provincial health plan for hospital accommodations up to a daily maximum of $100
- Other hospital services
- Hospital out-patient services
- Services of a doctor (reasonable and customary charge according to locality).
- If you have single coverage — the out-of-pocket maximum is $400 per benefit year.
- If you have family coverage — the out-of-pocket maximum is $800 per benefit year: $400 out of pocket maximum for the plan member alone, and a $400 out of pocket maximum for all eligible dependents combined.
The out of pocket amount is the percentage you pay for services reimbursed at 75% or 80%. Once you reach the out-of-pocket maximum, all expenses for the remainder of the year will be reimbursed at 100%.
The benefit year is calculated from January 1st to December 31st.
Note: All dollar maximums, frequency limits, reasonable and customary fees and any other contractual limitations still apply.
Quebec legislation requires that you, your spouse and children must be covered under a group health insurance plan providing at least drug coverage if you are under age 65 and are eligible for coverage under that plan. Only those employees who can provide proof they have health coverage under another plan, can refuse coverage under the McGill Supplemental Health Plan. See the RAMQ website for more information.
The amount you pay for your coverage will depend on whether you select coverage for:
- You alone ("single" coverage) or;
- You and your eligible spouse and children ("family" coverage).
You may opt out of the Supplemental Health Plan if you can provide written evidence that you are covered under another supplemental health plan -- eg. as a dependent under your spouse's plan. See details in Life Events.
Your coverage under the plan will end when you leave the University (before retirement), fail to qualify for coverage under the terms of the plan, or opt out of the plan altogether.
Coverage for your spouse and children will end when yours does. In addition, coverage will end on an individual basis when your family members are no longer eligible under the terms of the plan — for example, when a son or daughter marries or begins full-time employment.
Please refer to Life events for more details.
If you become disabled
Your coverage under the Supplemental Health Plan will continue while you are eligible for benefits under the Long-Term Disability Plan, provided you continue to pay your share of plan costs.
If you die
If you die before retirement and you had family coverage, your spouse and eligible dependent children can choose to continue coverage under the Plan for up to three months, provided they pay both their share and the University's share of the cost.