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:

• Pay Direct Drug Card
• drugs, serums, and vaccines, which legally require a prescription
• drugs for treatment of infertility
• colostomy supplies
• prescription contraceptives
• weight loss drugs
• erectile dysfunction
• prescription Nicorettes (up to 525 units per person per year)
• smoking cessation products that have a Drug Identification Number (DIN) or a Natural Product Number (NPN) and are prescribed by a doctor or dentist and dispensed by a pharmacist
• insulin, including needles, syringes, and chemical diagnostic aids
• 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:

• mandatory generic substitution
  • This means that if there is a generic drug available for your prescription, the pharmacy will automatically substitute the generic drug, unless the prescribing physician or health professional stipulates no substitution, in which case reimbursement will be based on the cost of the drugs prescribed.
  • If your physician requires no substitution, they must stipulates “no substitution” on the prescription. The pharmacist will dispense the brand name drug and you will not have to pay the difference between the brand name and the generic equivalent.
  • If there is no indication on your prescription from your physician stipulating “no substitution”, the pharmacist will substitute the generic version where available. In this case, if you choose to take the brand name and there is a generic equivalent, you will have to pay the difference between the two.
• drugs must have a Drug Identification Number (DIN)
• 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)
  • if you will be out of the country for more than three months, please submit a request to HR to coordinate an exception with Sun Life. 
• maximum one glucometer per person’s lifetime
• claims for prescription Nicorettes must be submitted on a paper claim. Claims for this expense cannot be paid using the drug card.
• smoking cessation products are covered to a lifetime maximum of $1000
• erectile dysfunction drugs are covered to a maximum of $2500 per year
• weight loss drugs are covered to a maximum of $1200 per year
• 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

Description of services:

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

For more detailed information about the application process, please log in to AskHR. 

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. To learn more about how our coverage connects to OHIP, please log in to AskHR.
• 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 $3000 every three 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

Description of services:

• ​​claims for medical cannabis must follow a prescribed process and only certain medical conditions are eligible for medical cannabis to be considered as treatment of symptoms  
• currently, only the following conditions are covered:
  • severe or refractory cancer pain
  • neuropathic pain with MS or Rheumatoid Arthritis
  • nausea and vomiting with cancer treatments
  • anorexia with HIV/AIDS
  • spasticity with MS
  • palliative care
  • refractory spasticity with spinal cord injury
  • refractory pediatric onset epilepsy

Maximums and limitations:

• $2000 per person per year based on Sun Life’s criteria and process
• you and your doctor must complete a prior approval form and submit to Sun Life for review

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, please log in to AskHR.

Descriptions 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

Maximums 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, please log in to AskHR.

Descriptions of services:

The following paramedical services are covered:

• physiotherapist
• speech therapist
• psychologist, psychotherapist, or social worker
• paramedical services including but limited to those provided by a acupuncturist, audiologist, chiropractor, kinesiologist, massage therapist, naturopath, occupational therapist, osteopath, podiatrist, or dietician

Maximums and limitations:

• practitioners must be licensed and/or registered in his/her province for the service to be covered
• physiotherapist
  • therapist must not normally reside in the patient’s home; must be prescribed by a doctor
• speech therapist
  • must be prescribed by a doctor
  • maximum per person: $2000 per year
• psychologist, psychotherapist, or social worker
  • combined maximum per person: $5000 per year
  • claims for psychotherapists must be for a registered/licensed psychotherapist
• paramedical services including but limited to those provided by a acupuncturist, audiologist, chiropractor, kinesiologist, massage therapist, naturopath, occupational therapist, osteopath, podiatrist, or dietician
  • maximum reimbursement per person is 20 treatments per practitioner per benefit year (subject to reasonable and customary limits)
  • only one X-ray examination per benefit year ordered by each licensed practitioner
  • massage therapy must be prescribed by a doctor and includes services provided by a RMT and registered shiatsu massage therapist (CST)
    • total of 20 treatments per year combined
  • 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
• services of an ophthalmologist or licensed optometrist

Maximums and limitations:

• prescription glasses including prescription sunglasses and safety glasses with corrective lenses.
  • maximum benefit of $1000 every two years* for any combination of the following:
    • prescription glasses
    • prescription contact lenses
    • laser eye correction surgery 
• services of an ophthalmologist or licensed optometrist
  • limited to one examination per person in any 12 month period

Note: the current two-year period ends December 31, 2022.