Frequently asked questions (FAQ)

Regarding the SMART program. Is there an appeal process for plan members if a required drug is excluded from coverage?  

There is no option to appeal a drug that does not meet the criteria for eligibility under Canada Life plans. 

Is there a list (or website) indicating which drugs would currently trigger the HCM process?  

The  HCM Drug Listing (pdf) document identifies 27 drugs that currently trigger the HCM process.

How is HCM information updated and communicated to plan members?  

The HCM process is triggered by Prior Authorization.  All HCM drugs are on the prior authoriszation list: HCM Drug Listing (pdf). Upon submission of the prior authorization form, the HCM case manager will contact the employee and initiate the process; there is nothing further the member needs to do. 

Would having the health case manager working with the member and the member’s physician trigger any out-of-pocket costs for the plan member (i.e., fees from the doctor to fill in certain forms)?  

There are no fees from Canada Life associated with this service.  In Canada Life’s experience, there are no fees charged to the employee by the doctor.  The employees would be working with specialists who are accustomed to completing forms for coverage.   

What assurances can you provide that data privacy is being handled appropriately by Canada Life / Health Forward?  

Canada Life Privacy Guidelines are in place to ensure full protection of plan members’ information.

Paramedical Practitioners

What services will no longer require a doctor’s note? 

The following services will no longer require a doctor’s note (i.e., physician referrals) effective May 1, 2021: Massage Therapists, Speech Therapists, Psychologists, and Dieticians.

Are kinesiologists currently covered by the Health plan?  

Kinesiologists are not covered.

Vision

Why was vision coverage not added? 

Changes to the benefit plan had to be cost neutral as there are no additional funds for benefits. Survey results indicated that introducing employee premiums or increasing the out-of-pocket maximum was not favourable, so vision coverage could not be added due to the corresponding cost.

Chiropractic coverage

Questions coming soon.

Invitro Fertilization

Who is covered for in-vitro fertilization and how much is covered? 

A lifetime maximum of $30,000 per member is covered. This maximum should enable two IVF attempts through the plan (in addition to the first attempt covered through provincial healthcare). Provincial coverage in Ontario requires a patient to be under 43 years old and as such, the University plan design should align accordingly.   

Who should I contact if I have questions about in-vitro fertilization? 

Effective May 1, 2021, plan members can contact Canada Life directly.  

What expenses are eligible for coverage? 

Included expenses are those that are a part of the in-vitro fertilization process. Coverage available through provincial healthcare programs must be exhausted first. 

Eligible expenses: 

•  anesthetist fees 

• cycle monitoring fee 

• 1 ultrasound and blood test once the in-vitro procedure has begun (usually just 1 is required to confirm pregnancy)

• embryo freezing - initial process, preparation and annual storage (annual storage limit of 1 year)   

• embryo thawing  

• in-vitro fertilization procedure  

• sperm thawing  

• sperm washing  

• transfer of frozen embryo 

Ineligible expenses:   

• embryo donation program (fee paid to a recognized clinic or qualified medical practitioner)  

• donation to a sperm bank  

• donor’s fee or cost  

• medical expenses or services incurred by the surrogate mother  

• surrogate agency fee  

• surrogate mother’s fee 

Generic Drugs

Will employees need to cover the difference in cost between generic and brand name drugs?  

Effective May 1, 2021 the plan will only cover the cost of the generic drug unless the member is approved for the brand name drug through Canada Life’s exception request process.  

Can members complete the Brand Exception Form (pdf) and start working with their doctors on getting this completed ahead of May 1, 2021?  

Members can access the Canada Life Brand Exception Form (pdf) (formerly branded as Great-West Life).  Processing of the form by Canada Life will commence May 1, 2021. 

Would the fee charged by the doctor to fill in the Brand Exception Form be covered by the University’s plan?  

Your doctor may charge for the form. The fee is not eligible for reimbursement under the plan. 

Is there an appeal process if the exception isn’t granted by Canada Life?  

Per Canada Life “there is no need for an appeal process as the only time it would be declined is if the request for brand form is not completed, or rather if a medical reason for the brand is not indicated on the form.” 

If I currently have a non-generic drug prescription and want to get another refill that I still have, do I need a new prescription from my doctor? 

Prior to May 1, you can still get the Brand refilled. May 1st onwards, the plan will only reimburse up to the generic equivalent unless medical evidence is provided to Canada Life through the Brand Exception Form (pdf). The process applies equally to new prescriptions as well as to refills.

Continuous Glucose Monitors

Will I need a doctor’s note (physician’s referral)? 

General

Are vaccines not covered by OHIP, covered in our plan? 

Travel vaccines are covered under the plan. Vaccines used in routine immunization would not be covered as they are covered by the provincial plan.  Eligible vaccines would be covered at 80% and subject to the $7.00 dispensing fee limit.  For specific coverage questions, please contact Canada Life at 1-800-957-9777. 

Why was dental coverage for retirees not considered part of the health plan? 

These are separate programs within Canada and viewed separately today in the University environment; cash and accounting cost increases weren’t possible.

Was reducing the LTD benefit considered as a means to fund other plan enhancements? 

This avenue was investigated by the working group; however, the employee stakeholder groups weren’t comfortable with such a change. The LTD benefit is fully paid for by employees based on level of earnings and diverting these employee contributions to another benefit irrespective of earnings level, was determined to be detrimental to some of the employee population.   

Will these changes impact retirees? 

Yes. Medical plan enhancements will apply to individuals who retired on or after June 6, 2000 with benefit plan coverage.

Why was dental coverage for retirees not considered part of the health plan? 

These are separate programs within Canada and viewed separately today in the University environment; cash and accounting cost increases weren’t possible.

Was there a recent change in adjudication practices at Canada Life with respect to compound drug prescriptions?  

There has been no change to the adjudication of compound drugs.

Plan change implementation