What type of expenses does the EHC plan cover?
This page outlines your extended health care covered expenses, limitations and exclusions.
The plan covers prescription drug expenses that are medically necessary in relation to the nature and severity of the illness.
To find out if a specific drug is covered you can call Sun Life at 1-800-361-6212.
Is there an upper limit to my reimbursement under the medical plan?
The drug plan covers eligible expenses up to $1000 per person per year.
See Specifics of Coverage for information about individual limits, and Ineligible expenses, limitations and exclusions for a list of ineligible expenses.
Covered services and supplies
The plan reimburses 50% of the following expenses up to an annual maximum of $1000, There is a $25 single and $50 family annual deductible.
Please note the benefit year runs from January 1 to December 31.
Prescription drugs and diabetic supplies
Description of services:
- pay direct drug card
- drugs, serums, and vaccines which legally require a prescription
- prescription contraceptives, including intrauterine devices (IUDs) and diaphragms
- insulin, including diabetic supplies
- colostomy supplies
- drugs for treatment of infertility
- Nicorettes, if prescribed by a doctor
- life-sustaining drugs which may not legally require a prescription
- glucometers, including reagent strips, when recommended in writing by a diabetologist or a specialist in internal medicine
Maximums and limitations:
- mandatory generic drug substitution
- if there are medical reasons why you cannot take the generic drug, your doctor will need to complete the (PDF file) Drug Exception Application form and submit it to Sun Life for approval
- dispensing fee cap of $9
- Maximum $1000 reimbursement per person
- requires a doctor’s written prescription and must be dispensed by a doctor or licensed pharmacist
- Nicorettes maximum is 515 units per year
- pharmacist may limit your prescription to a three-month supply (varies based on drug prescribed)
- see Ineligible expenses, limitations and exclusions for exceptions
- does not include over the counter medications, even if prescribed
- for employees continuing to work past age 65 or for those with eligible dependents over age 65, coverage for prescription drugs is provided through the Ministry of Health and Long Term Care under the Ontario Drug Benefit (ODB) plan as the primary payer
- information on the ODB plan may be obtained from your pharmacist or from the Ministry of Health website (external link)
- eligible prescription drug claims not covered by the ODB plan as well as the ODB yearly deductible and per prescription dispensing fees may be submitted to Sun Life as second payer
What expenses are not covered by the EHC?
Payment is not made for:
- baby foods and formula, minerals, proteins, vitamins and collagen treatments
- any charge for the administration of serums, vaccines and injectable drugs
- anti-obesity treatments including drugs, proteins and dietary or food supplements and hair growth stimulants, whether or not prescribed for medical reasons
- drugs for the treatment of sexual dysfunction
- any portion of the expenses for which reimbursement is provided by a government plan
- drugs and treatment that are used for cosmetic purposes
- natural health products, whether or not they have a natural Product Number (NPN)
- drugs and treatment, 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
- drugs that are available without a prescription even if prescribed
- services or supplies payable or available (regardless of any waiting list) under any government-sponsored plan or program except as stated in the Master Plan Document
- services or supplies that are not approved by Health Canada or other government regulatory body for the general public
- services or supplies that are not generally recognized by the Canadian medical profession as effective, appropriate and required in the treatment of an illness in accordance with Canadian medical standards
- services or supplies that do not qualify as medical expenses under the Income Tax Act (Canada)
- expenses for services performed by a person ordinarily a resident in the patient's home or a close relative
- any portion of the expense for which reimbursement is made due to the legal liability of another party
- charges incurred for an illness due to or resulting from the hostile action of any armed forces, insurrection or participation in a riot or civil commotion
- charges incurred for an illness due to or resulting from any cause for which indemnity or compensation is provided under any Workers' Compensation Act, Criminal Injuries Compensation Act or similar legislation
- charges incurred for an illness due to or resulting from the commission or attempted commission of a criminal offence by the covered person
- charges incurred for an illness due to or resulting from intentionally self-inflicted injuries
- charges incurred for an illness due to or resulting from optional services which are mainly for cosmetic purposes
- charges for equipment deemed by the Insurer not to be and eligible expenses (e.g. orthopaedic mattresses, exercise equipment, air-conditioning or air-purifying equipment, whirlpools, humidifiers etc.)
- any portion of the services or supplies over the reasonable and customary charges in the locality where they are provided.
TMU reserves the right, at any time, to amend, change or discontinue any benefit coverage. If there is a question about coverage referred to in any portion of this benefits communication, the master contract from the insurer is the governing document.