Member Benefits

Extended Health

Extended health coverage helps reimburse eligible expenses not covered by the provincial health insurance program. Plans may include coverage for prescription drugs, paramedical practitioners, vision care, medical supplies and services, and out-of-province emergency medical services.

Eligible expenses

Eligible expense may be any service and/or supply included in the summary of benefits that:

  • in the benefits provider’s assessment is a customary charge, medically necessary for health care and maintenance, or to maintain or restore teeth, and
  • was ordered or referred by a physician, dentist, or primary healthcare nurse practitioner (PHCNP), unless otherwise specified in the benefit description, and
  • is not a cost normally paid (in whole or part) or provided by a government plan or any other provider of health coverage and
  • is incurred while your coverage is valid. An expense is “incurred” on the date the service is provided or the supply is received, and
  • is provided by a practitioner or provider approved by the benefits provider. It does not include any payment to a pharmacy or a practitioner (demanded or received by balanced billing, extra billing, or extra charging), representing an amount in excess of the schedule of costs prescribed by the government plan. Provincial/territorial plans, low-cost alternatives, and reference drug programs will not be applied unless specified in the summary of benefit

Integration with Government Plans

Extended health care benefits are intended to supplement and not overlap benefits under government plans such as the Medical Services Plan (MSP) and Fair PharmaCare Program of British Columbia. As a condition of coverage, you are required to take all reasonable steps to qualify and obtain the fullest extent of coverage, benefits, contribution, or reimbursement available under all applicable government plans. The benefits provider will also make payment only where permitted by provincial/territorial legislation or other applicable laws.

Out-of-Province/Territory Non-Emergency Eligible Expenses

The benefits provider will reimburse you (and your dependents) for non-emergency Eligible expenses incurred while travelling outside your province/territory of residence subject to the deductible, in-province/territory reimbursement percentage, and maximums. The benefits provider will not reimburse expenses payable or provided under a government plan.

Out-of-Province/Territory Emergency Eligible Expenses

While travelling outside your province/territory of residence, benefits are payable for the following eligible expenses incurred IN AN EMERGENCY ONLY and when ordered by the attending physician. Non-emergency continuing care, testing, treatment, and surgery, and amounts covered by any government plan and/or any other health coverage provider are not eligible.

  • Local ambulance services when immediate transportation is required to the nearest hospital equipped to provide the treatment essential to the patient.
  • The hospital room charges and charges for services and supplies when confined as a patient or treated in a hospital for a maximum of 90 days.

If reasonably possible, the benefits provider should be notified within five days of the patient’s admission to the hospital. When the patient’s condition has stabilized, the benefits provider has the right, with the approval of the attending physician, to move the patient by licensed ambulance service to the hospital nearest the patient’s home, which is equipped and has space available to provide further medical treatment. Where transportation would endanger the patient’s health, the 90-day limit may be extended with the provider’s express written consent.

  • Services of a physician and laboratory and x-ray services.
  • Prescription drugs in sufficient quantity to alleviate an acute medical condition.
  • Other emergency services and/or supplies if the benefits provider would have covered them inside your province/territory of residence.

Emergency Travel Assistance

Medi-assist provides assistance to eligible members and their dependents who experience emergencies while traveling outside of their province of residence. Click here for information about what is covered and how to contact Medi-assist.

Exclusions

The following are not included as eligible expenses under your plan:

  • except as specifically included in the summary of benefits: dentures or dental treatments, hearing aids, eyeglasses, contact lenses, surgical lens implants, or examinations for the prescription or fitting of any of these, x-rays, hospital coinsurance, vitamins and/or minerals, erectile dysfunction drugs, medications used to treat or replace an addiction or habituation, support stockings, orthotics, arch supports, transportation charges incurred for elective treatment and/or diagnostic procedures or for health or health examinations of any kind, and professional services of physicians, dentists, or primary healthcare nurse practitioners, or any person who renders a professional health service in the patient’s province/territory of residence
  • general anesthetic, medications used to prevent baldness or promote hair growth, food replacements or supplements, infant food, HCG injections, drugs not approved for sale and distribution in Canada, and medications available without a prescription
  • except as specifically included in summary of benefits: anti-obesity drugs, sclerosing agents, contraceptives, drugs and supplies for smoking cessation, fertility drugs, and any drug, vaccine, item or service classified as a preventive treatment or administered for preventive purposes, and which is not specifically required for treatment of an illness or injury
  • allergy testing, unless rendered by a naturopath
  • personal comfort items, items purchased for athletic use, air humidifiers and purifiers, services of Victorian Order of Nurses or graduate or licensed practical nurses, services of religious or spiritual healers, occupational therapy, services and supplies for cosmetic or experimental purposes, public ward accommodation, rest cures, and medical laboratory tests
  • charges for completion of forms or written reports, communication costs, delivery and mailing or handling charges, interest or late payment charges, non-sharable or capital costs levied by local hospitals, or charges for translating documents into English
  • any payment to a pharmacy, a practitioner, physician, dentist, or primary healthcare nurse practitioner (demanded or received by balanced billing, extra billing or extra charging) which represents an amount in excess of the schedule of costs prescribed by the government plan
  • that portion of a claim normally covered by the government plan which has been refused on the basis that the claim was not submitted within the government plan’s time limits
  • expenses incurred outside your province/territory of residence due to elective treatment and/or diagnostic procedures or complications related to such treatment
  • expenses incurred outside your province/territory of residence due to therapeutic abortion, childbirth, or complications of pregnancy occurring within two months of the expected delivery date
  • charges incurred outside your province/territory of residence for continuous or routine medical care normally covered by the government plan in your province/territory of residence
  • expenses of a dependent hospitalized at the time of enrolment
  • services performed by a physician, dentist, or primary healthcare nurse practitioner who is related to or resident with you or your spouse
  • services, medical supplies or equipment rendered by a provider or practitioner not approved by the benefits provider.
  • fees for ambulance services when an ambulance is called but not used
  • ambulance charges for work-related illness or injury assessed by the Workers’ Compensation Board to be your employer’s responsibility
  • retroactive coverage and payment of any expense, including drugs that receive special authorization from provincial/territorial plans
  • any other item not specifically included as a benefit.

Disclaimer:

The information contained on this website is provided for general information purposes only. Every effort has been made to ensure that this information is accurate, but this site is not a substitute for the official Plan documents, nor is it an employment contract. In the event there is a discrepancy between this website and the official Plan documents, the official Plan documents will prevail. For more information, or if you have questions about the information provided on this website please contact your School District Benefits Administrator.