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Medical Coverage

What type of expenses does the EHC plan cover?

This page outlines your extended health care covered expenses, limitations and exclusions.

The plan covers expenses that are medically necessary in relation to the nature and severity of the illness.

Similar to most plans, payment is limited to what is considered reasonable and customary in Ontario, regardless of where you incur the expense. In order to determine what is reasonable and customary, Sun Life uses guidelines published by professional associations governing the suppliers or service providers.

In cases where there is no such guideline, you will be reimbursed according to Sun Life’s experience. If an expense is not eligible under the EHC plan, you are responsible for its cost. 

TMU is proud to offer a comprehensive and robust benefit plan, but some expenses have limits and some are not eligible. This site describes limits on covered expenses and lists excluded expenses. To find out if a specific service or item 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 plan covers eligible expenses up to an unlimited overall lifetime maximum, but some eligible expenses are subject to maximums or limitations.

See Specifics of Coverage for information about individual limits, and Ineligible expenses, limitations and exclusions for a list of ineligible expenses.

If your doctor recommends a treatment, service, or medical supply that is not mentioned, call Sun Life at 1-800-361-6212. They will help you determine if the expense is covered and if it is subject to any restrictions.

Covered services and supplies

The plan reimburses 100% of the following expenses, unless otherwise stated after the $25 annual deductible has been paid.

Please note the benefit year runs from January 1 to December 31.

Description of services:

  • licensed ambulance for emergency service

Maximums and limitations:

  • to the nearest hospital equipped to provide the required treatment

Description of services:

  • coverage for the CA 125 blood test for ovarian cancer and the PSA blood test for prostate cancer

Description of services:

  • services of a dentist, including charges for braces or splints, for the repair or alleviation of damage to natural teeth if the damage resulted from an accidental blow to the mouth

Maximums and limitations:

  • services must be received within 12 months of the accident
  • payment will not exceed the amount for the procedure in the current provincial General Practitioner Dental Association Fee Guide in your province of residence

Description of services:

  • reimbursement is based on the evidence based reformulary drug plan and pay direct drug card detailed in the OPSEU drug benefit plan
  • drugs, serums and vaccines, which legally requires a prescription
  • prescription contraceptives
  • prescription smoking cessation therapies
  • diabetic and colostomy supplies 
  • glucometers, including reagent strips, when recommended in writing by a diabetologist or a specialist in internal medicine
  • glucometers, including reagent strips, when recommended in writing by a diabetologist or a specialist in internal medicine
  • continuous glucose monitor (CGM) receivers, transmitters or sensors for persons diagnosed with Type 1 diabetes, up to a maximum of $4,000 per person per year
    • a doctor’s note confirming the diagnosis is required.

Maximums and limitations:

  • dispensing fee cap of $9.00
  • multi-tiered drug plan covered at 100%, 70% or 50%
  • requires a doctor’s written prescription and must be dispensed by a doctor or licensed pharmacist
  • pharmacist may limit your prescription to a three-month supply (varies based on drug prescribed)
  • smoking cessation limited to lifetime maximum of $500.
  • maximum one glucometer per person’s lifetime
  • see Ineligible expenses, limitations and exclusions for exceptions
  • does not include over the counter medications, even if prescribed
  • prescription drugs are reviewed on an annual basis and may change tiers
  • 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

Description of services:

Provides supplement coverage for feminization or masculinization surgeries not covered under OHIP.

For more detailed information about the application process, please visit our Gender Affirmation Procedures page

Sun Life covers the following procedures when they are not available under the member’s public health care plan:

  • Blepharoplasty
  • Browbone reduction/construction
  • Cheek augmentation
  • Chest contouring (liposuction or lipofilling)
  • Chin augmentation
  • Gluteal augmentation (lip filling or implants)
  • Hairline reconstruction (to correct a receding hairline)
  • Jawbone reduction/reshaping/contouring
  • Liposuction of the waist
  • Pectoral implants
  • Permanent hair removal (laser or electrolysis) of excessive facial or body hair
  • Rhinoplasty
  • Rhytidectomy

You may also be eligible for at home care if required. Please review the menu item on private nursing care.

Maximums and limitations:

  • Gender Affirmation coverage is standard: We cannot deviate or customize
  • Any procedures available through OHIP are not covered under Sun Life 
  • To be eligible, the member/dependent must show proof that they have been approved for other gender-affirming surgery(ies) through OHIP. Learn more about how our coverage connects to OHIP.
  • Sun Life pre approval is required
  • Must be 18 years or older, including dependents
  • Surgeries and procedures must take place in Canada to be eligible for reimbursement
  • Travel or transportation costs are not eligible for reimbursement 
  • $10,000 annual maximum, up to $50,000 lifetime maximum

Descriptions of services:

  • hearing aid(s) and repairs to them (excluding batteries)

Maximums and limitations:

  • maximum of $1250 every five consecutive benefit years
  • must be prescribed by an otolaryngologist or ear, nose, and throat specialist
  • the time limit between purchases begins from the last date of purchase and is based on benefit years

Descriptions of services:

  • charges for semi-private or private room accommodation in an acute care hospital, less the OHIP-paid ward charges 

Maximums and limitations:

  • OHIP pays for ward accommodation
  • charges for semi-private and private room covered at 100%
  • deductible does not apply

Maximums and limitations:

  • must be ordered by a doctor and must be primarily for rehabilitation and not custodial care, up to the hospital's semi-private room rate or private room rate less OHIP paid ward charges
  • OHIP pays for ward accommodation
  • charges for semi-private and private room covered at 100%
  • deductible does not apply

Descriptions of services:

Covered medically necessary equipment and supplies includes the following if prescribed by a doctor:

  • medically necessary equipment rented (or purchased at insurer's approval) that meets the person's basic needs
  • trusses, crutches, casts, splints, or braces
  • artificial limbs or other prosthetic appliances (excluding dental prostheses), including replacements when medically necessary
    • for myoelectric limbs, payment is limited to the amount otherwise paid for standard-type limbs
  • oxygen, plasma and blood transfusions
  • colostomy supplies
  • elastic support stockings, prescribed by a doctor, to a maximum of two pairs every six months
  • external mammary prostheses if required as a result of surgery
  • aerochambers (a device used to help treat asthma), limited to one aerochamber per person per year
  • obus back forms, limited to one unit per person’s lifetime
  • wigs required as the result of an illness, or as the result of medical treatment of an illness, to a lifetime maximum of $500 per person

Maximums and limitations:

  • to verify current details on limitations, call Sun Life at 1-800-361-6212
  • if alternate equipment is available, eligible expenses are limited to the cost of the least expensive equipment that will meet basic medical needs

Descriptions of services:

  • custom-made orthopaedic shoes or custom-made orthotic foot supports

Maximums and limitations:

  • must be prescribed by a doctor, podiatrist or chiropodist to a maximum of one pair per person per year

For more information, visit Coverage for orthopaedic shoes and orthotics.

Description of services

The following services are covered in the event of an emergency:

  • room and board in a hospital up to the difference between the hospital’s ward rate and semi-private room rate, or up to the difference between the hospital’s semi-private rate and the private room rate, as applicable (including where permitted by law, any admittance, coinsurance, or utilization charges)
  • other hospital services
  • out-patient services in a hospital
  • services of a doctor

Maximum and limitations

  • if you require emergency medical care when travelling, the Medical Plan will cover eligible expenses not covered by OHIP, as long as the expenses are considered reasonable and customary in Canada
  • must have provincial health coverage (e.g. OHIP)
  • the Emergency Travel Assistance plan applies for a maximum of 180 days from the time you leave your province of residence
    • if you are hospitalized during this period, in-hospital service is covered until you are discharged
  • the maximum benefit for eligible expenses incurred outside of Canada is $1 million per person per lifetime

For more details, visit the travel emergency medical coverage.

Descriptions of services:

The following services are covered:

  • psychotherapist, psychologist or social worker
  • speech therapist
  • paramedical services limited to, those provided by chiropractor, massage therapist, naturopath, osteopath, physiotherapist or podiatrist

Maximums and limitations:

  • practitioners must be licensed and/or registered in his/her province for the service to be covered
  • psychotherapist, psychologist or social worker
    • maximum per person: $3500 per year combined
    • reimbursement subject to reasonable and customary limits
  • speech therapist
    • must be prescribed by a doctor
    • maximum per person: $1000 per year
    • reimbursement subject to reasonable and customary limits
  • chiropractor, massage therapist, naturopath, osteopath, physiotherapist or podiatrist
    • maximum reimbursement per person is 20 treatments per practitioner per benefit year (subject to reasonable and customary limits)
      • if there is medical evidence to support physiotherapy treatment beyond 20 visits, Sun Life will adjudicate on an exception basis
    • only one Xray examination per benefit year ordered by each licensed practitioner
    • massage therapy and physiotherapy must be prescribed by a doctor; massage therapy limited to 90 minute visits
      • claims for 90 minutes must be submitted as a hard copy to Sun Life
      • massages less than 90 minutes in length can be submitted electronically
    • podiatrist services in Ontario are payable only after OHIP has paid its annual maximum benefit

Check the Sun Life provider delisting

Sun Life regularly audits healthcare service providers. Sometimes the review of their claiming and administrative practices results in the provider being “delisted,” meaning their services are no longer covered. If you receive healthcare services or supplies from a delisted provider, Sun Life will not reimburse you for your expenses. You can still choose to obtain services from the delisted provider, however, your claim will be denied.

To view the delisted providers, log in to, external link and select the message for delisted providers under "Please read". For more information, or help logging into, external link, contact Sun Life directly at 1-800-361-6212

Reasonable and customary limits

Please contact Sun Life at 1-800-361-6212 for current reasonable and customary limits.

Descriptions of services:

  • services of a registered nurse (RN) or registered nursing assistant (RNA) who is licensed, registered, or certified through his/her respective organization
  • services of an eligible home care worker (Victorian Order of Nurses (VON) nurse, Red Cross Homemaker, practical nurse, or home service worker)

Maximums and limitations:

  • to be eligible for this benefit, you must not be confined to a hospital
  • RN or RNA: Maximum of $25,000 per year
  • eligible home care worker: Maximum of $5,000 per year if patient is not confined in a hospital
  • the nurse or home care worker may not normally reside in the patient’s home
  • Sun Life pre-approval is required

Descriptions of services:

  • prescription glasses, including prescription sunglasses and safety glasses with corrective lenses required for the correction of vision
  • prescription contact lenses
  • laser eye surgery
  • services of an ophthalmologist or licensed optometrist

Maximums and limitations:

  • prescription glasses, including prescription sunglasses and safety glasses with corrective lenses and prescription contact lenses
    • maximum combined benefit of $700 every 18 months
  • services of an ophthalmologist or licensed optometrist
    • limited to one examination in any  12 month period for any employees age 20-64, or in any 24 month period for dependents age 20-64
    • Note: eye exams for patients under 20 and 65 and over are covered by OHIP

Note: the current 18-month period is from January 1, 2022 to June 30, 2023.

Ineligible expenses, limitations and exclusions

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-inflected 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.

Ryerson 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.