Medical Coverage

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

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

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.