Group Benefits Plan Information

Overview of Extended Health Care Benefits

Manulife Financial will pay the Benefit Percentage of all Covered Expenses incurred for the care of an insured person. Payment is subject to the maximums shown for Covered Expenses after applying the Benefit Percentage and any other applicable Policy Provisions.

Covered Expenses

The expenses specified are covered if they are:

a) Medically Necessary for the treatment of an illness or injury of an insured person and recommended by a Physician;

b) incurred for the care of a person while insured under this Group Benefit Plan;

c) reasonable taking all factors into account;

d) used as prescribed or recommended by a Physician; and,

e) supported by Manulife Financial’s Due Diligence process and the decision made by Manulife Financial to include as a Covered Expense and shared with the Policyholder as required.

Note: The term illness as used above does not include infertility.

These Expenses are covered to the extent that:

a) they are Reasonable and Customary, as determine by Manulife Financial; and

Note: This does not apply to Professional Services. Professional Services are, however, subject to the individual practitioners maximums shown under the “Professional Services” tab

b) they are not covered under the Provincial Plan or any other government-sponsored program; and

c) they can legally be insured; and

d) if they are associated with any Drug, supply or service that was subject to the Due Diligence process, the process has been completed with the result that expenses for that Drug, supply or service are eligible under the Policy as of the date of approval as determined by Manulife Financial and shared with the Policyholder as required.

All Extended Health Care Benefits are paid as if the insured person were eligible under the Provincial Plan.

In the event that a Provincial Plan or government-sponsored program or plan or legally mandated program excludes, discontinues or reduces payment for any services, treatments or supplies formerly covered in full or in part by such plan or program, this Policy will not automatically assume coverage of the charges for such treatments, services or supplies, but will reserve the right to determine, at the time of change, whether the expenses will be considered eligible or not.

This Policy will not automatically assume eligibility for all Drugs, services and supplies prescribed. New Drugs, existing Drugs with new indications, services and supplies are reviewed by Manulife Financial using the Due Diligence process. Once this process has been completed, the decision will be made by Manulife Financial to include as a Covered Expense, include with Prior Authorization criteria, exclude or apply maximum limits.

Manulife Financial maintains a list of Drugs, services and supplies that require Prior Authorization. Prior Authorization, is applied to ensure that the therapy prescribed is Medically Necessary. Where there are Lower Cost Alternative treatments, or prescribing guidelines recommend alternative Drugs be tried first that are lower in cost, a person will be required to have tried an alternative treatment unless medical contraindications to alternative treatments exist.

At Manulife Financial’s discretion, medical information, test results or other documentation will be required from the Physician to determine the eligibility of the Drug, service or supply.

Manulife Financial has the right to ensure insured persons access Manulife Financial’s Exclusive Distribution channels where applicable when purchasing a Drug, service or supply. Manulife Financial may decline a Drug, service or supply purchased from a provider outside the Exclusive Distribution channel.

Adherence

Non-compliance may result in the Drug, service or supply no longer being eligible for reimbursement.

Disease Management Programs

Participation in a Disease Management Program may be required. Participation will be at the discretion of Manulife Financial.

Patient Assistance Programs

Manulife Financial may require an insured person to apply to and participate in any Patient Assistance Program to which the insured person is entitled. Manulife Financial reserves the right to reduce the amount of a Covered Expense by the amount of financial assistance the insured person is entitled to receive under a Patient Assistance Program.

Advance Supply Limitation

Payment of any Covered Expenses under this Benefit which may be purchased in large quantities will be limited to the purchase of up to a 3 months’ supply at any one time, except of covered Drug Expenses.

The maximum quantity of Drugs that will be payable for each prescription will be limited to the lesser of:

a) the quantity prescribed by the Physician or Dentist; or

b) a 34 day supply.

A quantity of up to a 100 day supply may be payable in long term therapy cases, where the larger quantity is recommended as appropriate by the Physician and the Pharmacist.

Coverage provided by module

Blue	Green	Teal
60%	70%	80%

$1,000,000 maximum per person per calendar year (no out-of-pocket maximum)

The ManuScript Generic Drug Plan provides you and your Dependents with convenient Canada-wide coverage on your prescription Drug requirements.

Your Benefit is a Generic Drug plan, which means:

• The maximum amount for any Covered Expenses is the price of the Lower Cost Alternative Drug that can legally be used to fill the prescription, as listed in the Provincial Drug Benefit Formulary or a Lower Cost Alternative that provides therapeutically similar results as identified by Manulife Financial. (Subject to coinsurance and maximums).
• Manulife Financial can limit the Covered Expense for any Drug to that of a lower cost interchangeable Drug at the time the Drug is purchased.
• If there is no Lower Cost Alternative Drug for the prescribed Drug, the amount payable is based on the cost of the prescribed Drug. (Subject to coinsurance and maximums.)

Adjudication Notes:

• dispensing fees are subject to a maximum of $25 per prescription,
• ingredient costs and pharmacy mark-up fees are subject to Manulife reasonable & customary limits, plus a 10% margin under the ELCIC Group Benefits agreement.

No Substitution Prescriptions

Where a prescription contains a written direction from the Physician or Dentist that the prescribed Drug is not to be substituted with another product, the maximum amount covered is the price of the Lower Cost Alternative Drug that can legally be used to fill the prescription, as listed in the Provincial Drug Benefits Formulary of a Lower Cost Alternative that provides therapeutically similar results as identified by Manulife Financial.

If there is no Lower Cost Alternative Drug for the prescribed Drug, the amount payable is based on the cost of the prescribed Drug.

Reimbursement at the cost of a prescribed Drug, where a Lower Cost Alternative Drug is available, will only be considered if medical evidence is provided by the treating Physician to support why Lower Cost Alternative cannot be tolerate or is ineffective.

The amount payable is subject to any Drug Deductible, any Drug Dispensing Fee Maximum, the Benefit Percentage for Drugs and any maximum stated in the Policy

My drug plan tool is a personalized user friendly online tool to provide you with information what is covered and information about the drugs you are prescribed. Access My Drug Plan member eCard by computer, tablet or mobile device.

Charges incurred for the following when prescribed in writing by a Physician or Dentist, and dispensed by a Licensed pharmacist up to the maximum Covered Expense in your selected module.

Drugs For Treatment of Illness or Injury

Charges that are covered:

• any Drug which by law or convention requires the written prescription of a Physician or Dentist (except listed as below in the charge not covered),
• life-sustaining Drugs,
• injectable medications (charges for a practitioner or Physician to administer injectable medications are not covered).

Charges that are not covered:

• Drugs, biologicals and related preparations which are administered in Hospital on an in-patient or out-patient basis;
• Drugs determined to be ineligible as a result of Due Diligence;
• fertility Drugs, anti-smoking Drugs and anti-obesity Drugs;
• Drugs used in the treatment of a sexual dysfunction.

Preventive Drugs

Charges that are covered:

• oral contraceptives;
• preventive vaccines and medicines (oral or injected).

Diabetic Supplies

Charges that are covered:

• standard syringes, needles and diagnostic aids, required for the treatment of diabetes.

Charges that not covered:

• cotton swabs, rubbing alcohol, automatic jet injectors and similar equipment.

Specialty Drug Care

The Specialty Drug Care program includes a preferred pharmacy network, pharmacy services, preferred pricing and case management services for Specialty Drugs. Specialty Drugs, as determined by Manulife Financial, are high cost medications used to treat complex chronic and life-threatening conditions; they may require special storage, handling and administration, (including injection and infusion), and involve a significant degree of patient education, monitoring and management. The services described below are applicable to insured persons who enroll in this program.

Case management services may include but are not limited to:

1. program introduction;
2. arrangement for medication dispensing and distribution;
3. disease and medication education;
4. therapy optimization;
5. coordination of efficacy tests to ensure therapy is working;
6. health coaching in 4 areas: nutrition, physical activity, smoking cessation and stress;
7. assistance locating and in applying for alternative sources of funding, which may include patient assistance programs or provincial funding;
8. coordination and transfer of prescriptions to the network pharmacy;
9. medication adherence monitoring; and
10. support with side effect managements.

The amount of health case management services will vary depending on the diagnosis, Drug and recommended treatment plan.

Specialty Drug Care pharmacy services include:

1. preferred pricing;
2. specialty medication management and expertise;
3. drug delivery to the location of choice – home, infusion clinic, or doctor’s office;
4. access to a 24/7 pharmacist hotline for consultation;
5. expertise in cold chain (temperature sensitive) drug management and shipping; and
6. expertise in managing infusions, injections, education and high touch oncology and biologic medication management.

Payment of Specialty Drugs

Where a Drug has been determined to be eligible under the Plan, and where other Drugs will provide therapeutically similar results, the program will provide and reimburse the lowest cost alternative Drug. In cases where the Physician provides medical evidence that the alternate Drug cannot be tolerated, or is ineffective for the patient, the prescribed Drug will be eligible for consideration. (Subject to maximums and co-insurance).

Manulife Financial may require the insured person to apply to and participate in any patient assistance program to which the insured person is entitled. Manulife Financial will co-ordinate benefits payable under the Policy with any benefits payable through a patient assistance program.

Due to current regulation in Quebec, Manulife Financial is unable to offer a preferred provider network in the province. At such time as the regulations change, Manulife Financial will make these services available.

Blue, Green or Teal Modules

Coverage is provided for charges for eye exams including refractions, when prescribed by an ophthalmologist. optometrist, or oculist

• $200 per 12 months for persons under age 18; and
• $200 per 24 months for person 18 and over.

Green or Teal Modules

Coverage is provided for charges for the following, when prescribed by an ophthalmologist. optometrist, or oculist:

• visual training, up to the $200 per lifetime,
• contact lenses if prescribed as medically necessary or required to improve vision to at least a 20/40 level with in the better eye, provided this level cannot be attained with glasses, up to $200 during any 24 months. (GSI note: this amount of $200 is in addition to the regular benefit amount in the Green and Teal Modules in the next tab.)

Coverage is provided for charges for the purchase and fitting of prescription glasses or elective contact lenses, as well as repairs, or elective laser vision correction procedures, when prescribed by an ophthalmologist. optometrist, or oculist as follows:

Blue	Green	Teal
none	up to  $250 during any 24 months	up to  $400 during any 24 months

Coverage % to maximums and limitations as set out in the table below. 
Please note that the maximums are applied to the plan member and each dependent.

Services provided by the following Certified, Licensed or Registered practitioners:

Practioners	Blue: Maximums & Limitations	Green: Maximums & Limitations	Teal: Maximums & Limitations
Coverage	Blue: 60%	Green: 70%	Teal: 80%
Acupuncturist	$300 per calendar year	$400 per calendar year	$500 per calendar year
Audiologist	$300 per calendar year	$400 per calendar year	$500 per calendar year
Chiropodist / Podiatrist	$300 per calendar year (combined)	$400 per calendar year (combined)	$500 per calendar year (combined)
Chiropractor	$300 per calendar year, plus $50 per calendar year for x-rays	$400 per calendar year, plus $50 per calendar year for x-rays	$500 per calendar year, plus $50 per calendar year for x-rays
Dietitian	$300 per calendar year	$400 per calendar year	$500 per calendar year
Osteopath	$300 per calendar year	$400 per calendar year	$500 per calendar year
Massage Therapist	$300 per calendar year	$400 per calendar year	$500 per calendar year
Naturopath	$300 per calendar year	$400 per calendar year	$500 per calendar year
Speech Therapist	$300 per calendar year	$400 per calendar year	$500 per calendar year
Physiotherapist / Athletic Therapist / Kinesiologist	$300 per calendar year (combined)	$400 per calendar year (combined)	$500 per calendar year (combined)
Psychologist or Clinical Therapist or Marriage and Family Therapist (MFT) or Masters in Social Work (MSW) or Registered Social Worker (RSW) or Registered Psychotherapist	$3,000 per calendar year (combined)	$4,000 per calendar year (combined)	$5,000 per calendar year (combined)

If you are unsure if your practitioner or therapist will qualify, please call Manulife first to confirm.

The recommendation of a Physician is not required for Professional Services.

Provincial Plans may pay part of the expenses for some of these Professional Services. Coverage for the balance of such expenses prior to reaching the Provincial Plan maximum may be prohibited by provincial legislation. In those provinces where such prohibition exists, expenses under this Benefit Program are payable after the Provincial Plan’s maximum for the benefit year has been paid.

Private Duty Nursing

Coverage: 100% to a maximum of $10,000 per calendar year.

Please note that the maximums are applied to the plan member and each dependent.

Covered Expenses include services which are deemed to be within the practice of nursing and which are provided in the patient’s home by:

• a registered nurse, or
• a registered nursing assistant (or equivalent designation) who has completed an approved medications training program.

Manulife Financial suggests that a detailed treatment plan be submitted with cost estimates before private duty nursing services begin. Manulife Financial will advise you of any benefit that will be provided.

Charges for the following services are not covered:

• service provided primarily for custodial care, homemaking duties, or supervision;
• service performed by a nursing practitioner who is an Immediate Family Member or who lives with the patient;
• service performed while the patient is confined in a hospital, nursing home, or similar institution;
• service which can be performed by a person of lesser qualification, a relative, friend, or a member of the patient’s household.

Ambulance

Charges for licensed ambulance service provided in the insured person’s province of residence, including air ambulance, to transfer the patient to the nearest hospital where adequate treatment is available.

Medical Equipment and Supplies

Coverage: 100%, with the exception of insulin pumps covered at 50%, subject to maximums and limitations.

For all medical equipment and supplies covered under this provision, Covered Expenses will be limited to the cost of the device or item that adequately meets the patient’s fundamental medical needs and is approved by Manulife Financial.

For all medical services and supplies expenses Manulife Financial requires a written recommendation from the prescribing physician, including diagnosis, and a copy of the provincial plan statement of payment (if applicable).

Medical Supplies	Maximums and Limitations
Mobility equipment such as crutches, canes, walkers and wheelchairs (1)	rental of, or when pre-approved by Manulife Financial, the purchase of
Durable medical equipment including manual hospital beds, respiratory and oxygen equipment, and other durable equipment usually found only in hospitals	rental of, or when pre-approved by Manulife Financial, the purchase of
External prostheses
Surgical stockings	A maximum of 4 pairs per calendar year
Surgical brassieres	A maximum of 4 per calendar year
Braces (other than foot braces), trusses, collars, leg orthosis, casts and splints
Stock-item orthopaedic shoes (2) and modifications or adjustments to stock-item orthopaedic shoes (2) or regular footwear	A maximum of $150 per calendar year (recommendation of either a Physician or a podiatrist is required)
Casted, custom-made orthotics (3)	A maximum of $400 per 3 calendar years (recommendation of either a Physician or a podiatrist is required)
Hearing aids - cost, installation, repair and maintenance of hearing aids (including charges for batteries)	A maximum of $1,000 every 5 calendar years
Ileostomy, colostomy and incontinence supplies
Medicated dressing and burn garments
Wigs and hairpieces for patients with temporary hair loss as a result of medical treatment or a medical condition	A maximum of $500 per lifetime
Oxygen
Microscopic and other similar diagnostic tests and services rendered in a Licensed laboratory in the province of Quebec	$1,000 per calendar year
Charges for the treatment of accidental injuries to natural teeth or jaw, provided the treatment is rendered within 12 months of the accident, excluding injuries due to biting or chewing

(1) Wheelchair claim guide

(2) Orthopaedic Shoes claim guide

(3) Orthotics member guide

No Extended Health Care benefits are payable for expenses related to:

a) any illness or injury arising out of or in the course of employment then the person is covered by or is eligible for coverage by workers’ compensation;

b) any illness or injury for which benefits are payable under any government plan or legally mandated program;

c) war, whether declared or undeclared, insurrection, the hostile action of any armed forces, willing participation in a riot or civil commotion or any service in the armed forces of any country;

d) the involvement in the commission or attempted commission of an assault, criminal offence or illegal act;

e) injuries sustained while operating a motor vehicle, either while under the influence of any intoxicant or if the insured person’s blood contained more than 80 milligrams of alcohol per 100 millilitres of blood at the time of injury;

f) charges for periodic check-ups, broken appointments, third party examinations, travel for health purposes, or completion of claim forms;

g) services or supplies

i) when there would have been no charge at all in the absence of insurance;

ii) when reimbursement would have been made under a government-sponsored plan in the absence of insurance;

iii) which are received from a medical or dental department maintained by an employer, association or trade union;

iv) which are required for recreation or sports but which are not Medically Necessary for regular activities;

v) which would have been payable by the Provincial Plan if proper application had been made;

vi) which are performed or provided by the covered person, an Immediate Family Member or a person who lives with the insured person;

vii) which are provided while confined in a Hospital on an in-patient basis;

vii) which are not specified as a Covered Expense under this Benefit;

h) medical or surgical care which is cosmetic; or

i) medical treatment which is not usual and customary, or which is Experimental or Investigational in nature.

In accordance with the requirements of the prescription drug insurance legislation in Quebec, An Act Respecting Prescription Drug (R.S.Q., c. A-29-01) and the regulations enacted under this act (hereinafter collectively the “Legislation”), the drug benefit provided under the Policy to covered persons who reside in Quebec will be administered as outlined here.

If a provision of the Policy or the information here is, in full or in part, contrary to the Legislation or any other law or regulation replacing it, that provision, or the part this is deemed to be contrary will be presumed to be amended to comply with the minimum requirements of the then applicable laws and regulations.

Covered Drug Expenses

The following expenses are covered:

• 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
• covered pharmacy services that are to be paid when the drug is on the RAMQ List; and
• drugs that are listed as a covered expense in the Policy, but are not on the RAMQ List.

Coverage for drugs on the List of Insured Drugs that is published by the Régie de l’assurance-maladie du Québec (RAMQ List)

The following provisions apply only to the coverage of drugs that are on the RAMQ List and pharmacy services for private plans listed in the Act Respecting Prescription Drug Insurance and the Health Insurance Act, for drugs that appear on the RAMQ list. For all other covered drug expenses, the provisions stated in the Policy will apply.

a) Percentage Payable by Manulife Financial

Prior to the annual out-of-pocket maximum being reached, the percentage of covered drug expenses payable under the Policy will be:

i) For any drug on the RAMQ List which is not otherwise covered under the terms of the Policy, the percentage payable is the percentage as set out by the then applicable Legislation.

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

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

1. the benefit percentage stated in the Policy, or

2. 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 the portion of covered drug expenses or covered pharmacy services which must be paid by an insured person in a calendar year, before the percentage payable under the Policy 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 the Employee and their Spouse is as stipulated in the Legislation and includes those portions of covered drug expenses and pharmacy services relating to a drug on the RAMQ formulary paid for dependent children.

For the purposes of calculating the out-of-pocket maximum for the Employee and their Spouse, those portions of covered drug expenses and covered pharmacy services paid for 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, stated in the Policy will apply, up to the annual out-of pocket maximum. Thereafter, the deductible will not apply.

d) Lifetime Maximums

Lifetime maximums, if any, stated in  the Policy will not apply to drugs on the RAMQ List or covered pharmacy services. Drug and covered pharmacy service coverage provided after the lifetime maximum amount stated in the Policy is reached is subject to the following conditions:

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

ii) the percentage payable by Manulife Financial for covered expenses is the percentage as set out by the then applicable Legislation.

e) Eligible Dependent Children

Eligible dependent children who are in full-time attendance at an accredited educational institution will be covered until the later of:

i) the age specified in the Policy, and

ii) age 26.

Drug coverage and covered pharmacy services provided for dependent children after the age stated in the Policy is subject to the following conditions:

• only drugs that are on the RAMQ List are covered, and covered pharmacy services performed for a drug on the RAMQ List
• the percentage payable by Manulife Financial for covered expenses is the percentage as set out by the then applicable Legislation.

f) Termination Age for covered Drug and pharmacy service Expenses

Provided the person is otherwise eligible for the drug benefit under the Policy, the Termination Age, if any, specified in the Policy will not apply. Drug coverage provided after the Termination Age specified in the Policy is subject to the following conditions:

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

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

iii) the percentage payable by Manulife Financial for covered expenses is the percentage as set out by the then applicable Legislation,

iv) the Annual Out-of-Pocket Maximum is as stipulated in the then applicable Legislation, and

v) the premium required for the drug coverage is the premium for Extended Health Care Benefit.

g) Continuation of Coverage – Concerted Work Stoppages

In the event of a strike, lock-out or other concerted work stoppages, coverages will continue until the later of:

i) the length of time, if any, specified in the Policy, and

ii) 30 days.

Premiums must be paid in order for coverage to be continued.

Coverage for Drugs That are Listed as a Covered Expense in the Policy but are not on the RAMQ List

With respect to drugs that are covered under the Policy but not on the RAMQ List, all the provisions stated in the Policy will apply.