The Members’ Health Plan covers a wide range of medical services and supplies beyond what your provincial health plan provides. The benefits provided by the Plan are summarized below. It is important to take the time to learn about how the Plan can protect your financial, physical and mental well-being.
Deductibles and benefit maximums apply individually to each eligible member of your family. Reimbursements will not exceed the reasonable and customary charges, as determined by the insurer.
Below is a general summary of your health benefits. For more details contact the Members’ Health Plan.
- 100% coverage for a wide range of in-Canada medications.
- 75% coverage for Special Authorization drugs.
- $5 deductible per prescription.
- 80% coverage up to benefit maximum.
- Maximum $500 coverage per calendar year for each of the following: massage therapist, physiotherapist/athletic therapist, naturopath, acupuncture, chiropractor, audiologist, dietician, podiatrist/chiropodist, occupational therapist, osteopath and speech therapist.
- Maximum $700 coverage per calendar year for psychologist/social worker.
- Eye exam – Maximum $125 every 12 months for dependent children under age 21.
- Eye exam – Maximum $125 every 24 months for you, your eligible spouse and/or dependent children age 21-25.
- Vision services and supplies – Maximum $400 every 24 months.
- 80% coverage, up to benefit maximum.
- Blood-glucose monitoring machine – Maximum 1 every 4 years.
- Insulin infusion pump – Maximum $6,300 every 5 years.
- Diabetic supplies, including syringes and lancets – Maximum $2,000 in a calendar year.
Ambulance and Hospital Room
- 100% coverage for ambulance service – no benefit maximum.
- 100% coverage for semi-private hospital room – no benefit maximum.
Out-of-Country Medical Expenses and Travel Assistance Coverage
- Emergency care – 100 % coverage for expenses required as a result of a medical emergency outside of Canada.
- Travel Assistance – Provides support and benefits for travellers in emergency medical situations worldwide.
Chronic Care, Respite Care, Private Duty Nurse
- 100% coverage for chronic care and respite care – $20 per day to a maximum of 90 days.
- 100% coverage for private duty nursing – Maximum $25,000 every 3 years.
Medical Travel in Canada
- $2,000 lifetime maximum.
- Round trip distance must be 1,000 kilometres or more.
Medical Supplies, Appliances and Equipment
- 80% coverage, up to benefit maximum (must be prescribed by a physician).
- Hearing aids – Maximum $1,200 every 4 years.
- Custom-made orthopedic shoes and orthotics (prescribed by a physician or podiatrist) – Maximum $500 each calendar year. (Invoice must include a detailed description of the type of orthotics, the casting technique used and the date dispensed. A copy of the detailed biomechanical exam or gait analysis is also required).
- Custom-made compression hose – Maximum $500 each calendar year.
- Hairpieces (required as a result of a medical condition) – Maximum $1,000 every 2 calendar years.
- External breast prosthesis – Maximum 1 (per side) every 12 months.
- Surgical brassieres – Maximum 2 every 12 months.
- Mechanical or hydraulic patient lifters (excluding stair lifts) – Maximum $2,000 per lifter (electric) once every 5 years.
- Outdoor wheelchair ramps – $2,000 lifetime maximum.
- Transcutaneous nerve stimulators – $700 lifetime maximum.
- Extremity pumps for lymphedema – $1,500 lifetime maximum.
Your health plan provides 100 percent coverage (less $5 per prescription deductible) for National Formulary base drugs consisting of:
- The drugs listed in the Emergis Inc. National Formulary in effect on the date of purchase.
- Fertility drugs to a lifetime maximum of $3,500.
- Smoking cessation drugs requiring a prescription to a lifetime maximum of $500.
- Vaccines to a maximum of $300 every two calendar years.
- Erectile dysfunction drugs with no limitations.
- Diabetic supplies, limited to syringes, disposable needles for use with non-disposable insulin injection devices, test strips and lancets. The maximum amount payable for diabetic supplies including syringes and lancets is $2,000 in a calendar year.
National Formulary supplementary drugs are eligible for 75 percent coverage (less $5 per prescription deductible) and consist of the drugs on the Emergis Inc. Special Authorization list in effect on the date of purchase.
Drugs on the base Saskatchewan Formulary in effect on the date of purchase are eligible for 100 percent coverage (less $5 per prescription deductible.)
Coverage is not available for:
- Expenses above the cost of the lowest-priced equivalent generic drug. (Brand name drugs are only covered if approved by Great-West Life.)
- Drugs eligible under a provincial drug plan.(Coverage is limited to the deductible amount and co-insurance you are required to pay under that plan.)
- Any single purchase of drugs which would not reasonably be used within 90 days.
- Drugs dispensed by a dentist or clinic or by a non-accredited hospital pharmacy.
- Drugs dispensed during treatment as an in-patient or an outpatient in a hospital.
- Allergy extracts.
- Drugs that are considered cosmetic, such as topical minoxidil or sunscreens, whether or not prescribed for a medical reason.
Your health plan provides coverage for out-of-hospital services from any of the health practitioners listed up to the benefit maximum, provided the health practitioner is licensed, certified or registered. The benefit maximums stated apply separately to each eligible practitioner (i.e., $500 maximum for massage therapist, $500 maximum for physiotherapist, etc.)
Licensed, certified or registered means licensed, certified or registered to practice the profession by the appropriate licensing, certification or registration authority of the jurisdiction in which the care and/or services are provided or, where no such authority exists, possessing a certificate of competency from the professional body that establishes professional standards of competency and conduct.
Covered vision expenses and limitations apply to each individual eligible family member. Benefit periods (i.e., 12- or 24-month periods) apply from the date of purchase of the service or supply. The frequency limit does not apply from your effective date of coverage. The date of purchase is the date the service or supply was paid for in full.
To confirm the date you or an eligible family member will be eligible for an eye examination or vision supplies, or to confirm the amount of coverage still available in the current benefit period, contact Great-West Life at 1-800-957-9777 or access Great-West Life GroupNet to view your Vision Coverage Balances and Next Possible Purchase Date report.
Eye examinations must be performed by a licensed optometrist or ophthalmologist.
Vision Services and Supplies
Vision services and supplies must be prescribed and/or provided by a licensed optometrist or ophthalmologist and provided by a qualified optician. Covered expenses include:
- Prescription glasses (frames and/or lenses).
- Contact lenses and contact lens service.
- Sunglasses with prescription lenses.
- Safety glasses with prescription lenses.
- Laser eye surgery.
- Visual training and therapy preformed in the office of a licensed optometrist or ophthalmologist.
- Blood-glucose monitoring machines and insulin infusion pumps must be prescribed by a physician to be eligible for 80 percent coverage. Frequency maximums apply.
- Your health plan also provides 80 percent coverage for novolin-pens or similar insulin injection devices using a needle, insulin infusion sets, and bloodletting devices including platforms.
- Diabetic supplies under prescription drugs are 100 percent covered (less $5 deductible) and are limited to syringes, disposable needles for use with non-disposable insulin injection devices, test strips and lancets.
- The maximum amount payable for diabetic supplies including syringes and lancets is $2,000 in a calendar year. This dollar maximum does not apply to blood-glucose monitoring machines and insulin infusion pumps.
Your health plan provides coverage for ambulance transportation, including air ambulance services, to the nearest centre where adequate treatment is available and where a licensed ambulance company provides services.
Coverage is also provided for a semi-private room and board in a hospital in Canada. A hospital is an institution that is legally termed a hospital, is open at all times offers in-patient accommodation, has a staff of one or more physicians available at all times, and continuously provides 24-hour nursing by graduate registered nurses.
Emergency care outside of Canada is covered if it is required as a result of a medical emergency arising while you or your eligible dependants are temporarily outside of Canada for vacation, business or educational purposes. This coverage is only applicable for people who live in Canada and are covered by the government health plan in their home province.
Emergency care is defined as covered medical treatment that is provided as a result of and immediately following a medical emergency.
A medical emergency is either:
- A sudden, unexpected injury; or
- The onset of a condition not previously known or identified prior to departure from Canada; or
- An unexpected episode of a condition known or identified prior to departure from Canada. An unexpected episode means it would not have been reasonable to expect the episode to occur while travelling outside of Canada. If a person was suffering from symptoms before departure from Canada, Great-West Life may request medical documentation to determine if, in the circumstances, it could have been reasonably anticipated that the person may require medical treatment while outside of Canada.
The Plan covers the following services and supplies when related to out-of-country care:
- Prescription drugs.
- Treatment by a physician.
- Diagnostic x-ray and laboratory services.
- Hospital accommodation in a standard or semi-private ward or intensive care unit, if the confinement begins when you or your eligible dependant is covered.
- Medical supplies provided during a covered hospital confinement.
- Paramedical services provided during a covered hospital confinement.
- Hospital outpatient services and supplies.
- Medical supplies provided out-of-hospital if they would have been covered in Canada.
- Out-of-hospital services of a professional nurse if prescribed by a physician.
- For emergency care only, ambulance services by a licensed ambulance company to the nearest centre where essential treatment is available.
If the patient’s condition permits the return to Canada, benefits are limited to the lesser of:
- The amount payable under this Plan for continued treatment outside of Canada.
- The amount payable under this Plan for comparable treatment in Canada plus the cost of return transportation.
No benefits will be paid for:
- Any further medical care related to a medical emergency after the initial acute phase of treatment. This includes non-emergency continued management or follow up care of the condition originally treated as an emergency.
- Any subsequent and related episodes during the same absence from Canada.
- Expenses related to pregnancy and delivery, including infant care:
- After the 34th week of pregnancy.
- At any time during the pregnancy if the patient’s medical history indicates a higher than normal risk of an early delivery or complications.
Travel Assistance (also referred to as Global Medical Assistance)
Travel Assistance is a separate type of coverage from out-of-country emergency medical coverage. Travel Assistance will provide support and benefits for you and your eligible dependants if an emergency situation occurs while travelling. Assistance coordinators are available 24 hours a day, seven days a week to help you arrange for appropriate medical care, verify your insurance coverage and provide necessary travel assistance.
In the event of a medical emergency, contact an assistance coordinator by calling the numbers located on the back of your Travel Assistance card. If you don’t have a Travel Assistance card, please contact the Members’ Health Plan.
Some of the benefits provided through Travel Assistance are listed below. Benefit maximums and limitations may apply.
- On-site advance hospital payment when required for admission up to a maximum of $1,000.
- Preparation and transportation home of remains in the event of death.
- Medical evacuation to a hospital in Canada equipped to provide treatment, or to the nearest hospital outside Canada.
- Return transportation home for minor children travelling with you that are left unaccompanied because of your hospitalization or death. Expenses will be covered up to a maximum of a one-way regular economy airfare per child.
- Costs of returning your vehicle home or to the nearest rental agency when illness, injury or death prevents driving up to a maximum of $1,000.
- Transportation and lodging for one family member joining a patient hospitalized on an in-patient basis for more than seven consecutive days while travelling alone. Benefits will be paid for the expense of one round trip economy airfare plus up to $1,500 in lodging expenses.
- Airfare expenses will be covered for you and one travelling companion, if prearranged, prepaid return transportation is missed because of hospitalization.
To establish the amount of coverage available for chronic care, respite care and services provided by a private duty nurse, you must apply for a pre-care assessment.
Coverage is available for:
- Chronic care provided in a hospital, nursing home or for home nursing care, for a condition where improvement or deterioration is unlikely within the next 12 months.
- Respite care provided at home or at a day program or as an in-patient admission to a facility where the patient would reside for a specific period of time.
- Services of a registered nurse, licensed practical nurse or registered nursing assistant who is not a member of your family, but only if the patient requires the specific skills of a trained nurse as prescribed by a physician. Care provided does not include homemaking or companionship duties. Charges will not be considered for services provided in hospital, or when the nurse normally resides in the patient’s home.
If you or your eligible dependants are referred away from home by your doctor for treatment by another physician within your own province, or elsewhere in Canada, and the round-trip distance is 1,000 kilometers or more, coverage is provided for the following expenses when accompanied by supporting documentation and receipts:
- Travelling expenses for the person requiring the treatment and one companion, if recommended by the attending doctor. Benefits are limited to either round-trip economy class travel or automobile fuel expenses. Taxi, car rental charges and automobile repair charges are not covered.
- Lodging expenses for the person requiring treatment and one companion, limited to moderate quality accommodation for the area in which the expense is incurred. Telephone and meal expenses are not covered.
In addition to the receipts for travel and lodging, you must submit written confirmation from your physician of:
- The nature of the patient’s medical condition.
- Referral to another physician for treatment and the nature of the treatment provided.
- The physician’s recommendation that the patient is to be accompanied if charges are claimed for a companion.
For full details regarding coverage for medical supplies, appliances and equipment, including applicable limitations, contact Great-West Life.
Other medical supplies, appliances and equipment covered by the Plan include the following, subject to Plan limitations, deductibles and maximums:
- Rental or, at the Plan’s discretion, purchase of certain medical supplies, appliances, and equipment, including but not limited to, breathing equipment, prosthetic equipment, orthopedic equipment, mobility aids, etc., prescribed by a physician.
- Rental or, at the Plan’s discretion, purchase of a manual wheelchair or a standard hospital bed. When deemed necessary, an electric wheelchair may be substituted. These charges will be allowable only if approved and prescribed by a physician.
- Charges for the initial placement of a non-myoelectric limb and artificial eyes, prescribed by a physician.
- Diagnostic x-rays and tests, when not covered under your provincial government health plan.
- Ostomy supplies including irrigation sets, bags, deodorants, pads, adhesives or skin creams when not covered under your provincial government health plan.