Health Care Benefits - CUPE Facilities Management

Depending on the treatment, the health care plan covers all or 85% of the cost of eligible health care expenses, subject to limits on certain benefits and a prescription drug dispensing fee cap. The expenses must be:

• Medically necessary (as determined by the insurance provider) for the treatment of illness or injury and, in most cases, prescribed by a licensed medical practitioner
• In the insurance provider's opinion, reasonable and customary expenses
• Not covered under the provincial plan or any other government-sponsored program
• Not in excess of any stated maximums
• Used as prescribed or recommended by a physician
• In the insurance provider's opinion due diligence for the drug, supply or service has been completed where required
• A medication that has been approved for use by Health Canada and assigned a drug identification number

New drugs, existing drugs with new indications, services and supplies are reviewed by the insurance carrier using their due diligence process. The insurance provider will decide to either i) include, ii) include with Prior Authorization criteria, iii) exclude or iv) apply maximum limits for the new or existing drug/services/supplies.

The insurance provider 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 alternatives, you or your eligible dependents may be required to have tried an alternative treatment. To see the list of drugs requiring prior authorization, login to the Manulife plan member site. The most up to date listing can be found under Forms - Plan Member Brochures.

At the insurance provider's discretion, medical information, test results or other documentation may be required to determine the eligibility of the drug, service or supply.

The insurance provider has the right to ensure you or your dependents access their exclusive distribution channels where applicable when purchasing a drug, service or supply.

The insurance provider may require you or your dependents to apply and participate in any patient assistance program(s) and reserves the right to reduce the amount of a covered expense by the amount of the financial assistance you or your covered dependents are entitled to receive under a patient assistance program.

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 covered in full or in part by such plan or program, this plan 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 the change, whether the expenses will be eligible or not. We suggest that you check with the insurance provider before incurring large expenses.

There are various exclusions whereby the insurance provider will not pay benefits for expenses incurred for or in connection with such as, but not limited to:

• Care, services or supplies which are not medically necessary, as determined by the insurance provider
• Care, services or supplies which are for primarily cosmetic purposes, except those which are related to reconstructive surgery required to repair or replace damages by disease or bodily injury
• Care or services which are experimental or investigational – not approved as an effective, appropriate and essential treatment of an illness or injury
• Rest cures, travel for health reasons, periodic health checkups or examinations for the use of third party
• A medical condition caused by or related to war (whether or not war is declared), participation in any civil commotion, insurrection or riot, or while serving in the armed forces
• Services or supplies to the extent they are available under any government plan (benefits under a government plan must be accessed first before any benefits are payable)
• Additional, duplicate or replacement appliances or devices. (Note: subject to prior written approval by the insurance carrier, this exclusion will not apply if the replacement is required as a result of pathological change or because the existing item can no longer be made serviceable due to normal wear and tear)
• The services of a physiotherapist who has an agreement with the provincial health insurance plan
• Committing or attempting to commit, a criminal act
• Fees for completion of claim forms or other documentation, transfer of medical files or failing to keep a scheduled appointment
• Drugs, injectables, supplies or appliances which are experimental or are not approved by Health Canada
• Care, services or supplies used as treatment to a lifestyle choice (as determined by the insurance provider)
• Benefits or that part of benefits which cease to be payable under any government plan
• Drugs, medicines, services or supplies required for the condition requiring hospitalization while you or your dependents is an in-patient in a hospital
• Services or supplies that are covered under the Emergency Travel Assistance plan

For combined health care and dental expenses that are subject to an 85/15% coinsurance arrangement, the maximum you will pay in a calendar year is $450 for a single person or $900 for a family. If you reach the maximum, you will be reimbursed at 100% for eligible expenses the remainder of that year. This co-insurance arrangement does not apply to internal maximums already defined within the plan such as:

• Paramedical services
• Vision care
• $6.11 dispensing fee cap

If your status changes between single and family coverage part-way through the year, any out of pocket expenses covered by the plan you've incurred towards the single or family maximum will be included in the combined maximum for that calendar year.

Example: You and your spouse incur eligible health and dental expenses from January to July totaling $6,000 for which the Western plan paid 85% ($5,100) and you were out of pocket $900. The remainder of the eligible expenses for the balance of the calendar year will be paid at 100%.

Reasonable and Customary Limitations apply to health care and dental benefits. This means claims are adjudicated based on the lowest of the:

• Prevailing amount charged for the same or comparable service or supply in the area in which the charge is incurred, as determined by the insurance provider
• Amount shown in the applicable professional association fee guide
• Maximum price established by law

Exclusions: There may be further exclusions to this coverage. Please read the information on this page under "What's Not Covered".

Effective January 1, 2025, each CUPE Facilities Management regular full-time member will be allocated $1,100 per calendar year for their Health Care Spending Account (HCSA).

Your Health Care Spending Account can be used to cover medical and dental expenses that are not covered (or only partially covered) by your Extended Health and Dental plan.

Exclusions: There may be further exclusions to this coverage. Please read the information on this page under "What's Not Covered".

Read details about the CUPE Facilities Management HCSA.

With the exception of two categories of drugs, most eligible prescription drugs are covered at 85% when prescribed in writing by a physician or dentist and dispensed by a licensed pharmacist. The drug must legally require a prescription. This includes compounded preparations provided at least one of the ingredients is eligible.

In addition, drugs that may not legally require a prescription, but are in an injectable format, or are life sustaining (as determined by the insurance provider), and identified in the therapeutic guide section of the current Compendium of Pharmaceuticals and Specialties may be covered. These include:

• Antianginal agents
• Antiarrhythmic agents
• Anti-inflammatories
• Anticholinergic preparations
• Antihistamines
• Antiparkinsonian agents
• Antihyperlipidemic agents
• Bronchodilators
• Glaucoma therapy
• Hyperthyroidism therapy
• Oral fibrinolytic agents
• Parasympathomimetric agents
• Potassium replacement therapy
• Topical enzymatic debriding agents
• Tuberculosis therapy

The plan also covers:

• Preventive vaccines and medicines (oral or injected)
• Insulin, needles, syringes, lancets and chemical testing agents for the management of diabetes.
• B6 and B12 injectable vitamins when used for weight loss
• Non-oral contraceptives, limited to a maximum of $50 per person per calendar year (this overall maximum includes expenses for contraceptive devices listed under Medical Aids, Appliances, Services and Supplies)

The following two categories of drugs are covered at 100%, up to the specified maximums shown below:

• Smoking cessation aids – to a lifetime maximum of $500 per person
• Fertility drugs – to a lifetime maximum of $12,000 per person

There are some items not covered by Western's health plan, including, but not limited to:

• 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 the insurance provider's due diligence process
• Vitamins (other than injected vitamins), vitamin/mineral preparations and food supplements
• Chelation therapy
• Drugs used in the treatment of sexual dysfunction, other than Caverject and Muse
• Hair growth stimulants
• General public products, whether or not prescribed
• More than a 3-month supply of a drug or medicine
• Dispensing fees that exceed the maximum

There are some items covered by Western's health plan that may also be covered by government programs (e.g. Assistive Devices Program). Please check with your healthcare practitioner to see if the item you require is covered by a government program.

Exclusions: There may be further exclusions to this coverage. Please read the information on this page under "What's Not Covered".

• Eye exams – up to $25 per exam
• Prescription glasses and contact lenses (includes repairs) – $300 per person every 24 months.
• Laser eye surgery may be claimed under the vision care benefit
• Lenses after cataract surgery for medically necessary contact lenses - $100 per eye lifetime maximum
• Visual training or remedial exercises – $10 per half hour
• Vision care supplies must be prescribed by an ophthalmologist or licensed optometrist for the correction of vision.
• Safety glasses and non-corrective glasses or non-corrective sunglasses are not covered.

Exclusions: There may be further exclusions to this coverage. Please read the information on this page under "What's Not Covered".

The plan covers the services of licensed practitioners, up to $15 a visit unless otherwise indicated. A Physician’s written recommendation is not required for practitioner services.

Practitioners include:

• Chiropractor - $15 per visit per covered person after the 15th visit per calendar year  (includes x-rays, up to $35 per person per calendar year)
• Massage Therapist
• Naturopath
• Speech Pathologist
• Physiotherapist
• Osteopath (Eligibility Memorandum)
• Podiatrist /Chiropodist - (includes up to $200 per calendar
  year for surgery performed by a podiatrist)
• Acupuncturist

Note: In addition to the coverage noted above, you may use your Health Care Spending Account to cover the remaining cost of the services outlined.

Exclusions: There may be further exclusions to this coverage. Please read the information on this page under "What's Not Covered".

The plan covers 85% of eligible expenses for:

• Semi-private or private room and board (not a suite) in an Active Treatment Hospital or Chronic Care Hospital in excess of the Hospital's standard ward accommodation charge

An eligible hospital must:

• Be licensed as a Hospital
• Have physicians and registered nurses on duty or on call 24 hours per day
• Be eligible to receive payments under a provincial hospital program

Confinement in an eligible hospital is covered regardless of the type of care being provided, such as rehabilitation, convalescent care, palliative care or drug and alcohol treatment.

Private hospitals that are not eligible to receive provincial funding are not eligible under the program.

Co-payment fees or similar charges for chronic care are not eligible for reimbursement.

Facilities not covered

• Federal hospitals
• Rest homes or homes for the aged
• Nursing homes/convalescent nursing homes
• Health spas or hotels

Exclusions: There may be further exclusions to this coverage. Please read the information on this page under "What's Not Covered".

The plan covers many medical services and supplies however; there are specific requirements and restrictions.  This website is not exhaustive and there may be additional items covered that are not outlined here.  Prior to incurring an expense, you are advised to submit a treatment plan and cost estimate to the insurance provider to determine eligibility and find out how much coverage you can expect. Reasonable and customary limitations apply and items must be deemed to be medically necessary by the insurance provider.

The plan covers the following expenses per covered person, such as:

• Custom-molded orthopaedic shoes, when prescribed by an orthopaedic surgeon, physiatrist, rheumatologist, physician, podiatrist or chiropodist - one pair per calendar year (the first $75 in a calendar year is not covered), or modifications to street shoes including scaphoid pads, torque heels, insoles, moulded arch supports etc. (limited to one pair per person in a calendar year)
• Custom-molded orthotics – one pair per calendar year to a maximum of $400, on the recommendation of a physician, chiropodist or podiatrist
• Wigs – for permanent or temporary hair loss as a result of medical treatment to a lifetime maximum of $700
• ObusForme products – up to $100 per 5 calendar years
• Enuresis equipment – up to $100 per calendar year
• Blood glucose monitors– up to $200 per calendar year
• Insulin jet injectors up to $350 per calendar year
• Transcutaneous Electrical Nerve Stimulation (TENS) machine, limited to 50% of the cost
• Intra-uterine devices (IUD’s) and contraceptive diaphragms – up to maximum $50 per covered person in a calendar year (this overall maximum includes expenses for non-oral contraceptive drugs listed under Drugs and Medicines)
• Mozes detectors, limited to the cost of three months rental
• Compression garments and medical supplies

The plan covers 85% of many other eligible expenses, such as:

• Diabetic appliances, insulin infusion pumps and accessories
• Hearing aids - cost, installation, repair and initial batteries, maintenance (excludes replacement batteries or hearing tests)
• Private duty nursing (for services that can only be delivered by a Registered Nurse (R.N.) or Registered Practical Nurse (R.P.N.) who is not ordinarily a resident in your home or related to you or your dependents). The insurance provider must pre-approve services in advance.
• Ambulance service, including air ambulance, to the nearest hospital where medical care can be provided, when necessary as a result of a medical emergency
• Rental or purchase of mobility equipment (e.g., crutches, canes, and walkers) and durable medical equipment (e.g. respiratory and oxygen equipment)
• Artificial limbs (when myoelectric prostheses are required, only the amount that would be paid for standard artificial limbs will be eligible), artificial eyes
• Rental or, at the insurance provider's option, purchase of a single-sized, standard-type hospital bed (includes single-sized mattress)
• Rental or, at the insurance provider's option, purchase of a wheel chair or scooter (may include costs for repairs - replacements will only be eligible if existing item cannot be repaired)
• Surgical supports (e.g., surgical elastic stockings up to a maximum of two per calendar year, six surgical brassieres per calendar year)
• External breast prostheses
• Stump socks - up to a maximum of six per calendar year
• Respiratory oxygen and equipment necessary for its administration
• Ileostomy, colostomy and incontinence supplies (excluding gloves)
• Tracheostomy supplies (excluding gloves)
• Diagnostic tests and services carried out in a licensed medical laboratory, in excess of benefits paid by the provincial plan
• Dialysis equipment
• Compressor and equipment necessary for its use
• Apnea monitor
• Equipment for treatment of cystic fibrosis
• Burn pressure garments
• Prostatic Specific Antigen (PSA) test - two tests per 12 consecutive months

Exclusions: There may be further exclusions to this coverage. Please read the information on this page under "What's Not Covered".

Effective July 1, 2024, the plan covers 85% of eligible expenses for: Services delivered by individuals who are registered by the College of Psychologists of Ontario, the College of Registered Psychotherapists of Ontario, the College of Nurses of Ontario, the College of Occupational Therapists of Ontario, the Ontario College of Social Workers, Ontario Registered Clinical Counsellor or the Canadian Registry of Marriage and Family Therapists.