Benefits

Summary

• 100% coverage for a wide range of medications.
• 75% coverage for Non-preferred and High-Cost Specialty drugs.
• No deductible.

Details

The Member’s Health Plan utilizes multiple formularies to determine what drugs are covered. Each of the formularies are managed by independent third-party providers who employ health pharmacists and industry experts to assess which drugs will be included in the formulary. Those formularies are:

• Saskatchewan Provincial Formulary Drugs (100%)
  The Saskatchewan Drug Formulary is a listing of the therapeutically effective, high quality drugs that have been approved by the Saskatchewan Ministry of Health for coverage under the Saskatchewan Drug Plan. It contains over 5,000 different drugs.
• GSC Formulary – Preferred Drugs (100%)
  Preferred drugs under the GSC formulary are eligible brand and generic drugs that are less expensive than other drugs but are within the same therapeutic class. These drugs are defined on the basis of need, safety, efficacy and cost.
• GSC Formulary – Non-Preferred Drugs (75%)
  Non-preferred drugs under the GSC formulary are eligible brand and generic drugs that usually have less costly alternatives within the same therapeutic class. These drugs are defined on the basis of need, safety, efficacy and cost.
• GSC Formulary – High-Cost Specialty Drugs (75%)
  High-cost Specialty Drugs are drugs generally prescribed for complex or ongoing medical conditions. Typically, these are high-cost medications that are often injected or infused (although some are taken by mouth). They usually require complicated treatment regimens, unique storage requirements, additional patient support or educational requirements, and are not typically stocked by most retail pharmacies. They are typically prescribed by specialists. These drugs are subject to prior authorization from GSC.

Diabetic Drug Supplies (100%)

The following diabetic drug supplies are covered at 100 percent up to a maximum of $2,000 in a calendar year:

• Insulin syringes
• Minimed syringes
• Test strips
• Lancets
• Disposable needles for use with non-disposable insulin injection devices
• Sensors for flash glucose monitoring machines (i.e., Freestyle Libre sensors)

Other eligible drugs (100%)

The drugs listed below are eligible for 100% coverage up to the applicable benefit maximum:

• Fertility drugs – $15,000 lifetime maximum.
• Smoking cessation drugs requiring a prescription – $500 lifetime maximum.
• Eligible vaccines – Maximum $300 every two calendar years.
• Drugs used to treat erectile dysfunction – No maximum.

Mandatory Generic Drug Substitution
Based on specific provincial health insurance plan regulations, where a generic equivalent drug exists, reimbursement will only be made up to the cost of the lowest priced equivalent drug.
If a medical practitioner indicates a brand name drug is medically required due to a serious medical reaction to at least two generic equivalent drugs, GSC must be provided with a copy of the “Health Canada Vigilance Adverse Reaction Reporting Form” (that can be obtained from the Health Canada website) to determine eligibility for payment of the cost of the prescribed drug. This form must be completed by the medical practitioner.

Prior Authorization
Certain drugs require prior authorization from GSC before your drug claim can be reimbursed. You can find out if your drug is covered or requires prior authorization either by checking your coverage under “Your Health Benefits” on GSC everywhere or contacting the GSC Customer Service Centre.

Prescription Drug Exclusions
The following drugs are not covered under the MHP:

• Drugs for the treatment of obesity.
• Reference biologic drugs that have an approved biosimilar.
• Vitamins that do not legally require a prescription.
• Products which may lawfully be sold or offered for sale other than through retail pharmacies, and which are not normally considered by practitioners as medicines for which a prescription is necessary or required, unless specifically identified and included as eligible in “Prescription Drugs.”
• Ingredients or products which have not been approved by Health Canada for the treatment of a medical condition or disease and are deemed to be experimental in nature and/or may be in the testing stage.

Saskatchewan Special Support Program
If you’re a Saskatchewan resident, you may be eligible to have a portion of your prescription drug expenses paid for by the provincial government through the Saskatchewan Special Support Program. If you receive a letter from GSC advising you to apply for SSP, follow the instructions in the letter and apply for SSP as soon as possible. If you don’t apply, your drug benefits will be suspended until GSC receives your information.
Note: Individuals or families who are covered under federal government programs, such as the federal Non-Insured Health Benefits Program or Veterans Affairs, are not eligible for the SSP. If this applies to you, please advise GSC accordingly.

Summary

• 80% coverage to a maximum of $500 per calendar year for each of the following: massage therapist, naturopath, acupuncture, chiropractor, audiologist, dietitian, podiatrist/chiropodist, occupational therapist, osteopath and speech therapist.
• 100% coverage to a maximum of $1,000 per calendar year for physiotherapist/athletic therapist (combined).
• 90% coverage to a maximum of $2,500 per calendar year for registered psychologist/social worker.

Details

You will be reimbursed for the above services up to the amount shown as long as the practitioner providing the service is licensed by their provincial regulatory agency, or is a registered member of a professional association recognized by GSC. To confirm if your practitioner is eligible for coverage, contact the GSC Customer Service Centre.

Summary

• Eye exams – Maximum $125 every 12 months for dependent children under age 21.
• Eye exams – 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.

Details

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, not 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 GSC at 1-888-711-1119 or access your GSC everywhere account.

Eye Examinations
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 performed in the office of a licensed optometrist or ophthalmologist.

Summary

• 80 percent coverage up to benefit maximum.
• Blood-glucose monitoring machine – Maximum one every four years.
• Insulin infusion pump – Maximum $6,300 per pump; one every four years.
• Flash glucose monitoring machine – No maximum.
• Continuous glucose monitoring machine including sensors and transmitters – Maximum $4,000 per calendar year.

Details

Diabetic Supplies
Diabetic supplies are eligible for 80 percent coverage and include:

• Novolin-pens or similar insulin injection devices using a needle.
• Bloodletting devices including platforms (not including lancets).
• Insulin infusion sets (not including infusion pumps).
• Insulin infusion pump supplies such as insulin pods, Omnipods, etc.

Diabetic Equipment

The following items may require pre-authorization. Contact Customer Service Center for complete details.

• Blood-glucose monitoring machines.
• Insulin infusion pumps.
• Flash glucose monitoring machines.
• Continuous glucose monitoring machines, including sensors and transmitters.

Summary

• 100% coverage for ambulance service – no benefit maximum.
• 100% coverage for semi-private hospital room – no benefit maximum.

Details

Reimbursement for professional land or air ambulance to the nearest hospital equipped to provide the required treatment or from the hospital to your residence when medically required as the result of an injury, illness or acute physical disability.
Reimbursement for a semi-private room in a public general hospital.

Summary

100% coverage for expenses required as a result of a medical emergency while travelling outside of your province of residence for vacation, education or business reasons, to a maximum of $5,000,000 per incident.

Details

“Emergency” means a sudden and unforeseen medical condition that requires treatment. An emergency no longer exists when the evidence reviewed by GSC Travel Assistance indicates that no further treatment is required at your destination, or you are able to return to your province/territory of residence for further treatment.
“Emergency” excludes treatment of a pre-existing condition that was not completely stable for the 90-day period immediately preceding the covered person’s departure.
“Pre-existing condition” means any medical condition that exists prior to the date of the covered person’s departure.
“Medical condition” means any disease, illness or injury (including symptoms of undiagnosed conditions).
A medical condition is considered “stable” when all of the following statements are true during the 90-day period immediately preceding the date of the covered person’s departure:

1. There has not been any new treatment prescribed or recommended, or change(s) to existing treatment (including stoppage in treatment).
2. The medical condition has not become worse.
3. There has not been any new, more frequent, or more severe symptoms.
4. There has been no hospitalization or referral to a specialist.
5. There have not been any tests, investigation or treatment recommended, but not yet complete, nor any outstanding test results.
6. There is no planned or pending treatment.
7. There has not been any change to an existing prescribed drug (including an increase, decrease, or stoppage to prescribed dosage), or any recommendation or starting of a new prescription drug. The following are not considered changes to existing prescribed drug treatment.

• Routine dosage adjustments of Coumadin, Warfarin, or insulin, as long as these medications have not been newly prescribed or stopped;
• A change from a brand name to a generic equivalent product as long as the dosage is the same-including a transition from a biologic to a biosimilar product;
• A decrease in the dosage of a medication due to the improvement of a condition.

All of the above conditions must be met during the 90-day period prior to the covered person’s departure in order for a medication condition to be considered stable.
You must contact GSC Travel Assistance within 48 hours upon admission to a hospital and commencement of treatment. (See GSC Travel Assistance Service.)
It’s important to review complete details regarding coverage and limitations prior to you leaving the country/province. Please refer to the Health Plan information booklet.

GSC Travel Assistance Service
GSC travel assistance service is available 24 hours per day, seven days a week through GSC’s international medical service organization.
You must contact GSC Travel Assistance within 48 hours upon admission to a hospital and commencement of treatment.

For assistance dial 1.800.936.6226 within Canada and the United States or call collect 0.519.742.3556 when traveling outside Canada and the United States. These numbers appear on your GSC Identification Card.

Quote your GSC Identification Number, found on your GSC Identification Card, and explain your medical emergency. You must always be able to provide your GSC Identification Number and your provincial/territorial health insurance plan number.

A multilingual Assistance Specialist will provide direction to the best available medical facility or legally qualified physician able to provide the appropriate care. Upon admission to a hospital or when consulting a legally qualified physician or surgeon for major emergency treatment, GSC Travel Assistance will guarantee the provider (hospital, clinic or physician) that you have the required provincial/territorial health insurance plan coverage and GSC travel benefits as detailed above.

GSC Travel Assistance will follow your progress to ensure that you are receiving the best available medical treatment. GSC Travel Assistance also keeps in constant communication with your family physician and your family, depending on the severity of your condition.

It’s important to review complete details regarding coverage and limitations prior to you leaving the country/province. Please refer to the Health Plan information booklet.

Summary

• 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 three years.

Details

Coverage is available for:

• Chronic care. Pre-authorization may be required. Contact GSC for details.
• Respite care. Pre-authorization may be required. Contact GSC for details.
• Reimbursement for the services of a Registered Nurse or Registered Practical Nurse/Licensed Practical Nurse  in the home on a visit or shift basis, up to $25,000 every 36 months. No amount will be paid for services which are custodial and/or services that do not require the skill level of a Registered Nurse or Registered Practical Nurse/Licensed Practical Nurse. A pre-authorization form must be competed by the attending physician and submitted to GSC.

Summary

• $2,000 lifetime maximum.
• Round trip distance must be 1,000 kilometres or more.

Details

If you or your eligible family members are referred by your physician for treatment by another physician within your own province, or elsewhere in Canada, and the round-trip distance is 1,000 kilometers or more, you may be eligible for coverage for transportation and accommodation.

All claims must be supported by documentation and receipts. Contact GSC prior to travel for information for specific details on coverage and claiming requirements.

Details

This is not a complete list of all covered medical supplies and equipment. Please contact GSC Customer Service Centre for complete details regarding coverage and claiming requirements.

• 80% coverage up to benefit maximum (when prescribed by a legally qualified medical practitioner). Prior authorization may be required for specific items.
• Hearing aids – Maximum $2,500 every four years.
• Footwear as described below – Maximum $500 each calendar year:
• Custom-made foot orthotics or repairs to custom-made foot by a physician, podiatrist, or chiropodist and dispensed by a podiatrist, chiropodist, chiropractor, orthotist or pedorthist).
• Custom-made boots or shoes and modifications and repairs or footwear as an integral part of a brace (subject to medical pre-authorization).
• Compression stockings (pressure measurement of 15 mmhg or higher) – Maximum $500 each calendar year.
• Wigs (required as a result of a medical condition) – Maximum $1,000 every two calendar years.
• External breast prosthesis – Maximum one (per side) every 12 months.
• Post-mastectomy bra – Maximum two every 12 months.
• Mobility aids such as canes, crutches, braces, casts, walkers, wheelchairs, hospital type beds, bathroom equipment.
• Incontinence/ostomy supplies such as catheters and ostomy supplies.
• Respiratory equipment such as compressors and inhalant devices, tracheotomy supplies.
• Mechanical or hydraulic patient lifters (excluding stair lifts) – Maximum $2,000 per lifter (electric) once every five years.
• Outdoor wheelchair ramps –  $2,000 lifetime maximum.
• Transcutaneous nerve stimulators (TENS machine) – $700 lifetime maximum.
• Extremity pumps for lymphedema –  $1,500 lifetime maximum.