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Supplemental health plan

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.

Insurance carrier:  Manulife Financial              Policy/contract number: 85210

Mandatory Participation

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.

For further information regarding opting out of the McGill Supplemental Health Plan, go here

Coverage

This section explains the benefits covered under the McGill Supplemental Health Plan, as well as what is not covered by the plan. 

Out of Pocket Maximum

  • 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.

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%.

Note: All dollar maximums,frequency limits, reasonable and customary fees and any other contractual limitations still apply.

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 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.                                                                               

A. Hospital services
B. Prescription drugs
C. Health practioners
D. Supplies & services
E. Out-of-province services 

A. Hospital services (100%)

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.

B. Prescription drugs (80%)

(For plan members 65+:  Please refer to Turning 65 for information about changes to drug coverage under the McGill Supplemental Health Plan).

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.

Generic drugs
If a generic equivalent exists for a brand name drug, the cost of the lowest generic equivalent will be reimbursed at 80%.

However, if the reimbursement amount of the lowest generic equivalent is less than the RAMQ reimbursement minimum, the brand name drug will be reimbursed according to the RAMQ reimbursement minimum.

For example, the RAMQ reimbursement minimum for July 2014-June 2015 is 67.5%.  If 80% reimbursement of the lowest generic equivalent is less than 67.5% reimbursement of the cost of the brand name drug, then the brand name drug will be reimbursed at 67.5%.

Brand name drug expenses will be reimbursed at 80% when the interchangeable generic drug is not available or the brand name drug is prescribed as not to be interchangeable or substituted ("No Substitution " or "No generic" is indicated on the prescription).

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.
By purchasing the generic equivalent instead of the brand name drug, the plan member’s savings in their out-of-pocket expense can be as high as $44.95 ($50.60-$5.65), and the savings to the Health Plan can be as high as $101.96 ($124.55-$22.59).
The third example (No Substitution) illustrates the amount reimbursed, and out-of-pocket expense, if your doctor indicates ‘no substitution’ on the prescription.

Drug 

Lipitor             

Cost*              Percentage reimbursed Dollar amount reimbursed

Out-of-pocket amount

(pd by member)

Generic (10 mg)

$28.24 (90 pills) 80% $22.59 $5.65

Brand (10 mg)

Member's choice

$155.69 (90 pills) 67.5%** $105.09 $50.60

No substitution

(10 mg)

$155.69 (90 pills) 80% $124.55 $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:

http://www.ramq.gouv.qc.ca/en/publications/citizens/legal-publications/Pages/list-medications.aspx

**Because 80% of the generic ($22.59) is less than 67.5% of the brand, the plan is obliged by the RAMQ to reimburse at 67.5% of the brand.  

Drugs covered:

  • 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 drugs, Xenical and Meridia, up to a lifetime maximum of $2,400

Drugs not covered:

  • anti-obesity treatments, other than Xenical and Meridia for each person
  • anti-impotence treatments
  • anti-smoking treatments
  • 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
  • the cost of giving injections, serums or vaccines
  • drugs dispensed and distributed through prescription on-line sites(Internet pharmacies)

Note: Drug coverage ends at age 65.  Please refer to Life Events for more information.

C. Health practitioners (80%)

The plan covers the following services when REFERRED BY A DOCTOR, subject to the outlined limits and restrictions:

Private duty nursing — up to $30,000 during any consecutive 60-month period for nursing care performed at the patient's residence (other than a convalescent or nursing home). 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 licenced social worker who is a member of the Order of Social Workers.

Physiotherapy, occupational therapy, athletic therapy, or speech therapy. — for services performed by a licenced physiotherapist, licenced occupational therapist, licenced certified athletic therapist, or licenced speech therapist up to a combined maximum of $750 per person each benefit year.

Chiropractors, osteopaths, acupuncturists, or dieticians — for services performed by a licenced chiropractor, licenced osteopath, licenced acupuncturist, licenced dietician to a combined maximum of $300 per person each benefit year. This includes one x-ray per benefit year by each licensed practitioner.

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.

D. 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):

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 - such as needles, syringes, reagent strips, cotton and alcohol swabs for the treatment of diabetes.

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. Tests performed in a doctor's office or a pharmacy are not covered; as well as diagnostic services performed by an audiologist.

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 Submitting Claims 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.

E. Out-of-province medical services (100%)

Emergency Travel Assistance

H is for Health

For important coverage details, refer to the Emergency Travel Assistance section on this website.

Reminder:
Unstable political and environmental conditions in some countries may affect availability of emergency medical or assistance services. For more info on travel conditions, consult the Travel Bulletin, published by the Consular Affairs Bureau, Federal Dept of Foreign Affairs.

Non-emergency referrals

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).

What the plan does not cover

In addition to any exclusions listed on the previous pages, 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, 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).
  • services of a naturopath, massage therapist, podiatrist or audiologist
  • eyeglasses, contact lenses, laser eye surgery and expenses of an opthtalmologist 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
    • 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)
  • Effective January 1, 2010: 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.

Paying for your coverage

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).

For definitions of "spouse" and "children", please refer to Defining your "family". Similarly, see Rate summary for plan costs.

Opting out

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.

When coverage ends

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.