REIMBURSEMENT: 100% 
MAXIMUM: $5,000 per person per calendar year, includes pay direct drug card*

* Individuals whose drug costs are high relative to family income are encouraged to apply for coverage under the Special Support Program through the Government of Saskatchewan Drug Plan. You are encouraged to contact Saskatchewan Health Care Officials at 1-800-667-7581 for any assistance of the application process.

Sun Life will cover the cost of the following generic drugs and supplies that are prescribed by a doctor or dentist and are obtained from a pharmacist. As mandatory generic substitution is a feature of your drug plan, the plan will only reimburse your prescription drugs up to the lowest priced (usually generic) equivalent, if one exists. There may be valid medical reasons for not substituting your brand name drug with a lowest priced equivalent. If so, you and your doctor will need to complete a Drug Exception Application form. If the reasons are accepted by Sun Life, the plan will cover the cost of the brand name drug. Drugs covered under this plan must have a Drug Identification Number (DIN) in order to be eligible.

• drugs that legally require a prescription.
• life-sustaining drugs that may not legally require a prescription.
• injectable drugs and vitamins
• intrauterine devices (IUDs), diaphragms, diabetic and colostomy supplies.
• vaccines.
• prescribed anti-smoking drugs, which legally require a prescription, are limited to a lifetime maximum of $1,000.

Sun Life will not pay for the following, even when prescribed:

• infant formulas (milk and milk substitutes), minerals, proteins, vitamins and collagen treatments.
• the cost of giving injections, serums and vaccines.
• treatments for weight loss, including drugs, proteins and food or dietary supplements
• hair growth stimulants.
• drugs for the treatment of sexual dysfunction.
• drugs for the treatment of infertility
• drugs that are used for cosmetic purposes.
• natural health products, whether or not they have a Natural Product Number (NPN).
• drugs and treatments, and any services and supplies relating to the administration of the drug and treatment, administered in a hospital, on an in-patient or out-patient basis, or in a government-funded clinic or treatment facility.
• To avoid any out-of-pocket expenses, we recommend you always use your Pay-Direct drug card.

• Drug Card and Mandatory Generic Substitution

EYE EXAMS: $150 per person every two calendar years
VISION CARE MAXIMUM: (glasses/contacts/corrective eye surgery) $400 per person every two calendar years

Eye Exams
Services of an ophthalmologist or licensed optometrist.

Vision Care
Contact lenses or eyeglasses prescribed by an ophthalmologist or licensed optometrist and obtained from an ophthalmologist, licensed optometrist or optician, or laser eye correction surgery performed by an ophthalmologist will be covered.

In addition, the vision care plan will cover the cost of contact lenses or intraocular lenses following a cataract surgery, limited to a lifetime maximum of one lens per eye.

Sun Life will not pay for sunglasses, magnifying glasses or safety glasses of any kind, unless they are prescription glasses needed for the correction of vision.

REIMBURSEMENT: 100%
MAXIMUMS
Physical Wellness: The maximum for each type of practitioner is $500 per person in a calendar year
Mental Health: The combined maximum is $2,000 per person in a calendar year

Charges for the following licensed or registered practitioners:

Physical Wellness

• acupuncturist
• chiropractor
• chiropodist/podiatrist*
• naturopath
• osteopath
• physiotherapist
• registered massage therapist
• speech therapist

Mental Health*

• clinical counsellors
• marriage and family therapist
• psychologist
• psychotherapist
• social worker

*Subject to a combined maximum

Dual-licensed practitioners will be assigned a primary type and all claims for that practitioner will be reimbursed under the maximum for that primary practitioner type.

 Most paramedical expenses fall within the reasonable and customary fee range. If a health care practitioner chooses to charge more, the member is responsible for the extra cost.

Supplies, equipment and services

REIMBURSEMENT: 100%
MAXIMUM: Unlimited unless defined otherwise

Note

• Only medically necessary services or supplies for the treatment of an illness or a bodily injury are covered.
• Some services or supplies may require a physician’s prescription (e.g., private duty nursing, medical equipment, elastic support stockings)
• Coverage may be limited to the reasonable and customary charges for the product or service being claimed.
• To ensure reimbursement, it is recommended that you contact Sun Life to find out detailed limits/maximums information before purchasing the medical equipment and/or supplies.

Preferred Accommodation
Semi-Private/Private – the difference between the cost of a ward and a preferred in-hospital accommodation, when requested by the participant.

Convalescent Hospital
The cost of room and board in a convalescent hospital, if this care has been ordered by a doctor, as long as it is primarily for rehabilitation and not for custodial care. The maximum amount payable is $20 per day up to a maximum of 180 days for treatment of an illness due to the same or related cause.

Ambulance
Charges for transportation in a licensed ambulance, as well as air ambulance, if medically necessary, that takes you to the nearest hospital that is able to provide the necessary medical services.

Private Duty Nursing
Out-of-hospital private duty nurse services when medically necessary. Service must be for nursing care, and not for custodial care. The private duty nurse must be a nurse or nursing assistant who is licensed, certified or registered in the province where you live and who does not normally live with you. The services of a registered nurse are eligible only when someone with lesser qualifications cannot perform the duties. There is a limit of $10,000 per person during any one benefit year.

Accidental Dental
Dental services, including braces and splints, to repair damage to natural teeth caused by an accidental blow to the mouth that occurs while you are covered. These services must be received within 12 months of the accident. Sun Life will not cover more than the fee stated in the Dental Association Fee Guide for a general practitioner in the province where the employee lives. The guide must be the current guide at the time that treatment is received.

Medical Equipment
Medically necessary equipment rented, or purchased at Sun Life’s request, that meets your basic medical needs. If alternate equipment is available, eligible expenses are limited to the cost of the least expensive equipment that meets your basic medical needs. For wheelchairs, eligible expenses are limited to the cost of a manual wheelchair, except if the person's medical condition warrants the use of an electric wheelchair.

Prosthetic Appliances
Charges for the following remedial prosthetic appliances or supplies:

• wigs required due to a medical condition and prescribed by a physician will be covered to a maximum of $500 per person in a calendar year.
• casts, splints, trusses, braces or crutches.
• breast prosthesis required as a result of surgery, up to a maximum of one per participant every two calendar years (two if a double mastectomy).
• surgical brassieres required as a result of surgery, up to a maximum of two brassieres per calendar year.
• artificial limbs and eyes.

Repairs and/or adjustments are limited to no more than the cost of a new appliance.

Diabetic Supplies
Charges for the following diabetic supplies in a quantity prescribed by a physician and deemed reasonable by Sun Life Financial; i.e. needles, syringes, swabs, test tapes and lancets.

Diabetic Equipment
Continuous Glucose Monitor (CGM), including receivers, transmitters, and sensors, for persons diagnosed with Type 1 or Type 2 diabetes requiring insulin use, up to a combined maximum of $4,000 per person per benefit year. Sun Life requires a doctor’s note confirming both the diagnosis and insulin use.

Medical Supplies
Charges for:

• elastic support stockings, including pressure gradient hose
• stump socks

Hearing Aids
Charges for hearing aids prescribed by an ear, nose and throat specialist, up to a maximum of $500 per person over a period of three calendar years. Dependent children less than 21 years of age, requiring a hearing aid for each ear, are eligible for two hearing aids (one for each ear) to a maximum expense of $500 per person for each hearing aid over a period of three calendar years. Repairs are included in these maximums.

Cochlear Implants
Charges for cochlear implants including upgrades to implants but excluding batteries and warrantees, up to a total expense of $1,000 per person in three calendar years, when prescribed by an otologist or clinical audiologist.

Orthopaedic Shoes/Orthotic Inserts
Charges for custom-made orthopaedic shoes, modifications to orthopaedic shoes, or custom- made orthotic inserts for shoes, when prescribed by a doctor, podiatrist or chiropodist, up to reasonable and customary limits. Orthopaedic shoes and orthotic inserts are limited to one pair each per person per calendar year.

Mobility Aids
Charges for the purchase of bathroom rails, bath seats, raised toilet seats or reachers, on the written authorization of a physician.

Blood Pressure Monitors
Charges for the purchase or rental of a blood pressure monitor on the written authorization of a physician, limited to one every five calendar years based on reasonable and customary limits.

Cardiac Rehabilitation
Charges up to $300 per lifetime for treatment rendered to cardiac patients under a recognized cardiac rehabilitation program prescribed by the attending physician for:

• rehabilitation after myocardial infarction, coronary bypass surgery or valve replacement; or
• the management of angina pectoris or other diagnosed cardiac disease.

100% for emergency services: Global Excel Management (GEM) must be contacted immediately in order to coordinate the coverage of all eligible expenses.
Lifetime maximum of $3,000,000: out-of-country coverage for emergency services; within Canada, Saskatchewan Health is first payer of your medical expenses
80% for referred services: based on a referral from a doctor in your province of residence.

Sun Life will cover emergency services while you are outside the province where you live, as well as referred services. For both emergency services and referred services, Sun Life will cover the cost of:

• a semi-private hospital room.
• other hospital services provided outside of Canada.
• out-patient services in a hospital.
• the services of a doctor.

Expenses for all other services or supplies eligible under this plan are also covered when they are incurred outside the province where you live, subject to the reimbursement level and all conditions applicable to those expenses.

Emergency services

Emergency services mean any reasonable medical services or supplies, including advice, treatment, medical procedures or surgery, required as a result of an emergency. When a person has a chronic condition, emergency services do not include treatment provided as part of an established management program that existed prior to the person leaving the province where the person lives.

Emergency means an acute illness or accidental injury that requires immediate, medically necessary treatment prescribed by a doctor.

At the time of an emergency, you or someone with you must contact Sun Life’s Emergency Travel Assistance provider, GEM. All invasive and investigative procedures (including any surgery, angiogram, MRI, PET scan, CAT scan), must be preauthorized by GEM prior to being performed, except in extreme circumstances where surgery is performed on an emergency basis immediately following admission to a hospital. If contact with GEM cannot be made before services are provided, contact with GEM must be made as soon as possible afterwards. If contact is not made and emergency services are provided in circumstances where contact could reasonably have been made, then Sun Life has the right to deny or limit payments for all expenses related to that emergency.

An emergency ends when the covered person is medically stable to return to the province where the person lives.

Emergency services excluded from coverage

Any expenses related to the following emergency services are not covered:

• services that are not immediately required or which could reasonably be delayed until the person returns to the province where the person lives, unless their medical condition reasonably prevents the person from returning to that province prior to receiving the medical services.
• services relating to an illness or injury which caused the emergency, after such emergency ends.
• continuing services arising directly or indirectly out of the original emergency or any recurrence of it, after the date that Sun Life or GEM, based on available medical evidence, determines that the person can be returned to the province where the person lives, and the person refuses to return.
• services which are required for the same illness or injury for which the person received emergency services, including any complications arising out of that illness or injury, if the person had unreasonably refused or neglected to receive the recommended medical services.
• where the trip was taken to obtain medical services for an illness or injury, services related to that illness or injury, including any complications or any emergency arising directly or indirectly out of that illness or injury.

Referred Services

Referred services must be for the treatment of an illness and ordered in writing by a doctor located in the province where you live. Your provincial Medicare plan must agree in writing to pay benefits for the referred services. All services must be obtained in Canada, if available, regardless of any waiting lists, and covered by the Medicare plan in the province where you live. However, if referred services are not available in Canada, they may be obtained outside of Canada.

Emergency Travel Assistance (Medi-Passport)

GEM can

• refer you to physicians, pharmacists and medical facilities
• confirm your coverage and benefits
• facilitate payments to a hospital or medical provider, whenever possible
• monitor the medical situation, if you are hospitalized

Your travel benefits can cover you for emergency medical services, including:

• all services and supplies while in hospital.
• outpatient and physicians’ services.
• ground ambulance service to the nearest hospital.
• transportation to the province where you live for medical treatment, if appropriate.
• hotel accommodation and meals if you have been released from hospital but GEM determined you are not yet able to travel.

In addition, with Medi-Passport you are also covered for additional support services, up to the maximum amounts under your plan:

• hotel accommodations and meals, if your return trip is delayed by a medical emergency involving a covered family member travelling with you.
• replacement transportation tickets, if you lose the use of your return ticket due to an emergency
• return home of unattended dependent children, if you are hospitalized.
• visit by a family member, if you are hospitalized for more than seven consecutive days.
• return of remains to your home province, in the event of death.
• return of your personal or rented car.
• help with arrangements for replacing lost or stolen travel documents and luggage.
• translation services, to help you communicate with local medical personnel.
• sending of urgent messages to your home or business.

Emergency Travel Contract Information

Outside Saskatchewan Travel Exclusions and Limitations

There are countries where GEM is not currently available for various reasons. For the latest information, please call GEM before your departure. GEM reserves the right to suspend, curtail or limit its services in any area, without prior notice, because of:

• terrorism, a rebellion, riot, military uprising, war, labour disturbance, strike, nuclear accident,  or an act of God.
• the refusal of authorities in the country to permit GEM to fully provide service to the best of its ability during any such occurrence

Before Travelling and Emergency Situations

Learn what you should know before your trip and what you should do in an emergency situation.

• Before travelling and emergency situations

Sun Life will not pay for the costs of:

• services or supplies payable or available (regardless of any waiting list) under any government-sponsored plan or program unless explicitly listed as covered under this benefit.
• services or supplies to the extent that their costs exceed the reasonable and usual rates in the locality where the services or supplies are provided.
• equipment that Sun Life considers ineligible (examples of this equipment are orthopaedic mattresses, exercise equipment, air-conditioning or air-purifying equipment, whirlpools and humidifiers).
• any services or supplies that are not usually provided to treat an illness, including experimental or investigational treatments. Experimental or investigational treatments mean treatments that are not approved by Health Canada or other government regulatory body for the general public.
• services or supplies that do not qualify as medical expenses under the Income Tax Act (Canada). 
• services or supplies for which no charge would have been made in the absence of this coverage.
• implanted prosthetic or medical devices (examples of these devices are gastric lap bands, breast implants, spinal implants and hip implants).

Sun Life will not pay benefits when the claim is for an illness resulting from: 

• the hostile action of any armed forces, insurrection or participation in a riot or civil commotion.
• any work for which you were compensated that was not done for the employer who is providing this plan.
• participation in a criminal offence.

If you and your eligible dependents are covered for similar benefits under two plans, you can maximize the amount of money you get back by coordinating your benefits.

• Coordination of Benefits

View claim procedures including coordination of benefits and submission deadlines.

• Submitting claims

Learn more about:

• Eligibility and effective date of coverage for you and your dependents.
• Termination of Coverage
• Converting your benefits to an individual plan
• Proof of Coverage for Health and Dental Benefits
• Premiums

• Coverage and Eligibility