Who is eligible?
To be eligible, all plan members must have provincial health coverage.
If you have been hired as a permanent employee to work at least 40% of a regular work week, you are entitled to coverage for you, your spouse and dependents.
If you have been hired for a term (temporary) position for a period of no less than 12 months, to work at least 40% of a regular work week, you are entitled to coverage for you, your spouse and dependents.
Your spouse is defined as someone to whom you are married legally or common law (defined as having lived with your partner for 12 months or more). This includes a spouse of the same sex.
Your dependent child is defined as an employee's or spouse's child who:
- is either under age 21 or under age 26 and a full-time student at an accredited school, college, or university; and
- is unmarried (legally or common law); and
- is not employed on a full-time basis; and
- is not eligible for benefits as an employee under this or any other group plan.
A child who is incapable of employment due to a mental or physical condition that occurred before reaching the maximum age will continue to be covered if approved by the insurance company.
Note: Dependents between ages 21 and 26 have the same coverage and restrictions as adults and not the same as dependents under age 21.
When would coverage begin?
Health Coverage starts on the first of the month following your date of eligibility.
If your employer offers this benefit as an optional benefit and you choose not to enroll and have no other extended health coverage (that is you have no health insurance outside of your provincial plan), you will be required to provide medical evidence of insurability if you wish to join the plan after 60 days of your eligible date to join and be approved for coverage.
When will coverage end?
Coverage ceases when you are no longer eligible or at the end of the month if your employment ends, whichever comes first. Note: Prescription Drug Cover for you and your spouse ceases at age 70. Refer to “Continuation of Coverage” for Retiree Coverage.
What is covered?
The plan covers drugs that require a written prescription, have a drug identification number and are on the Manulife Managed Formulary (this list is subject to change without notice). Prescription Drug Coverage for you and your spouse ceases at age 70. An electronic drug look-up tool is available. Please refer to the Manulife Plan Member Secure Website section on page 6.
For each prescription fill, you pay a co-pay which is $5.00 plus the dispensing fee for the lowest priced alternative (typically a generic) drug covered under the managed drug formulary. Please show your Benefits Card to your pharmacist. If you do not have a card, contact Group Benefits Solutions at 1-866-886-7246.
Prescription drugs are the biggest cost for your group plan. We manage the drug costs using the following strategies to support the plan members prescription drug needs and the sustainability of the plan.
The Manulife Managed Formulary features:
Defined drug list – The formulary is made up of a list of clinically-effective and affordable prescription drugs that are used to treat most medical conditions. For drugs that are not covered by your plan, a suitable alternative can usually be found within the formulary that offer similar, equally-effective medical results and is available at a lower cost. See Appendix A in the quick print document above for the defined drug list.
Prior authorization – With some medications, you may need to provide additional information to Manulife in order to determine if the drug is eligible for coverage. Prior authorization helps to ensure that certain medications are being prescribed for a medical condition or use that is approved by Health Canada and covered under your plan. Some higher-cost drugs may also require that you try a less costly alternative first. This helps you get the care that you need at an affordable price. See Appendix B in the quick print document above for the prior authorization list.
Lowest-cost alternatives – to help manage costs, your plan pays up to the cost of the lowest-priced alternative (typically a generic). Many brand name drugs have generic equivalents that are considered interchangeable. Generic drugs have the same active ingredients, so they are equally safe and effective as brand name drug, but they generally cost less. For more information, see the “Mandatory Drug Substitution” section below.
Mandatory Drug Substitution (Lowest Cost Alternative): Your plan will pay up to the cost of the lowest-cost alternative, typically the generic drug, even if a brand name medication is dispensed. If your healthcare professional prescribed a medication and indicated “no substitution” on your prescription, your pharmacist may contact them on your behalf in order to confirm that the generic medication can be dispensed instead. For those instances when your healthcare professional indicates there is a medically substantive need to remain on the brand name medication, please contact the Manulife Customer Service Centre toll-free at 1–855-626-4267 to seek approval for the brand name to be covered. Further information and forms are available on the Manulife Plan Member Secure Website.
Step Therapy: For many conditions there are a number of equally safe and effective treatment options from which to choose. Step Therapy makes it easier for you to get proven, safe and effective treatments for common conditions that require medication regularly in a way that can save money for you and the drug plan. The program applies to people who have one or more of the following common conditions and need to take medication regularly: gastrointestinal disorders, high blood pressure, diabetes, gout, high cholesterol, overactive bladder, enlarged prostate, rosacea and non-steroidal anti-inflammatory. Step Therapy is conveniently managed for you at the pharmacy. See Appendix C in the quick print document above for the Step Therapy Information.
For more information on your drug plan, contact Manulife Client Service toll-free at 1–855-626-4267.
Eye Exams: Eye exams are reimbursed at Manulife’s reasonable and customary (R&C) level. The total maximum eye exam (including retinal imaging) is once every two consecutive calendar years for you and your spouse, and once every consecutive calendar year for your dependents under age 21. When medically necessary, eye exams may be covered outside the regular schedule. Contact Manulife for prior approval.
Lenses and Frames: The Plan covers the R&C charges for prescribed lenses or contact lenses plus $150 for frames once every four consecutive calendar years for adults (once every two consecutive calendar years for eligible dependent children under age 21). Prescribed lenses or contact lenses are covered more often if there is a significant prescription change. If there is a significant change in prescription during the four-year coverage period (two years for dependents), you cannot switch your claim between glasses and contact lenses.
Visual Training: Visual training services are covered as required for the treatment of ocular muscle imbalance, or other medical condition(s) as approved by Manulife, to a lifetime maximum of $200 per person. These services are reimbursed at 100% of the eligible expense, as established and approved in advance by Manulife.
Laser Eye Surgery: Laser eye surgery is covered to a lifetime maximum of $200 per person.
When visiting your eye care professional, please bring a copy of the Vision Claim form. Forms are available on the Manulife Secure Site or www.healthassociation.ns.ca/benefits/forms.
For your convenience, you can also contact the Manulife Customer Service Centre toll-free at 1-855-626-4267 with questions about your vision benefit.
The calendar year maximum for practitioner coverage is $1,800 per year.
For each visit, you pay a co-pay of $10.00. There is no co-pay if you are visiting practitioners who provide counselling therapy, namely, psychologist, counselling therapist and social worker.
Services are reimbursed at a reasonable and customary (R&C) level. Any amount over this is not covered.
Paramedical practitioners must be licensed and certified within their respective fields of expertise, and validated/registered with Manulife.
The Plan covers up to the maximum in each calendar year for the combined services of a:
- Chiropodist or Podiatrist
- Counselling Therapist ($100 max per visit)
- Massage Therapist
- Occupational Therapist
- Social Worker
- Speech Therapist
The Plan does not cover charges for any treatment performed in a hospital that are covered under your provincial health plan.
There is a calendar year maximum of $35 per practitioner for x-rays.
Note: Reasonable and Customary (R&C) levels are the amount paid for a medical service in a geographic area based on what providers in the area charge for the same or similar medical service.
Other Eligible Supplies and Services
- Semi-private or private hospital room coverage.
- Professional ambulance, to nearest hospital , to a maximum of $1,000 in a calendar year.
- Private duty nursing, to a maximum of $10,000 in a calendar year (treatment plan must be submitted).
- Diagnostic X-ray services.
- Accidental dental treatment (treatment plan must be submitted within 180 days of the accident).
- Diabetic supplies (can use benefits drug card).
- Diabetic equipment, to a maximum of $700 in five calendar years (see medical supplies and equipment for insulin pumps).
- Ostomy supplies (can use benefits drug card).
- Speech aids, to a lifetime maximum of $500.
- Prosthetic/Remedial appliances or supplies. Some maximums and limits may apply. Repairs and adjustments are subject to a maximum of $300 in a calendar year.
- Hearing aids (one for each ear) to a maximum of $1,000 per hearing aid over three calendar years (includes batteries and repairs). Excludes hearing tests.
- Rental of Major Medical equipment: the rental or, when approved by Manulife, purchase of: Mobility Equipment: Crutches, canes (one per lifetime), walker, and wheelchairs (batteries and repairs are covered to a combined maximum of $1,000 per calendar year); and Durable Medical Equipment: manual hospital beds, respiratory and oxygen equipment, and other durable equipment usually found only in hospitals.
- Medical Supplies: includes but not limited to insulin pumps, compression pumps, continuous passive motion machines up to a maximum of $4,500 every 5 consecutive calendar years or rental cost up to a maximum of $450 per 5 consecutive calendar months, TENS machines to a maximum of $300 in 5 consecutive calendar years, and medicated dressings & burn garments up to a maximum of $500 per calendar year. See Appendix D in the quick print document above for the Medical Equipment Guidelines.
- Stock item orthopaedic shoes which have been modified (recommendation of a physician or podiatrist required) and custom-made shoes which are required because of a medical abnormality that, based on medical evidence, cannot be accommodated in a stock-item orthopaedic shoe or a modified stock-item (must be constructed by a certified orthopaedic footwear specialist), up to a maximum of $200 per calendar year for adults, and $300 per calendar year for eligible dependents. See Appendix E in the quick print document above for the Orthopaedic shoes guidelines.
- Casted, custom-made orthotics, up to a maximum of $300 per calendar year for adults, and $400 per calendar year for eligible dependents (recommendation a physician or podiatrist required). See Appendix F in the quick print document above for the Orhotics guidelines.
- Allergy serums, antigens, and antihistamines obtained with a written doctor’s prescription. For each of these there is a deductible of $50 per calendar year per person, to a maximum of $150 per family. The maximum benefit is $1,000 per calendar year.
- Vaccines are covered at 50% up to a lifetime maximum of $500. Some exclusions apply.
- Surgical stockings and support stockings: to a maximum of $200 in calendar year. Prescription required. See Appendix G in the quick print document above for Surgical Stockings guidelines.
- Foot care services provided by registered nurse in a foot care clinic to a maximum of $25 per visit up to $300 per person in a calendar year.
- Clinical measurement services: services related to biometrics to help you measure your blood pressure, sugar levels, cholesterol, weight and other biometric factors. Available only to the plan member. The maximum benefit is $100 per person in a year.
- Smoking cessation products: nicotine patches, nicotine gum, prescription medications, inhalers, and nicotine-free prescription medicine up to a combined maximum of $500 per person every 24 months. Prescription required.
What are the health exceptions?
No benefits are payable for expenses related to:
- any illness or injury arising out of or in the course of employment when the person is covered by or is eligible for coverage by workers’ compensation;
- any illness or injury for which benefits are payable under any government plan or legally mandated program;
- self-inflicted injuries or illnesses, whether the person is sane or insane;
- war, insurrection, the hostile action of any armed forces or participation in a riot or civil commotion;
- the committing of or the attempt to commit an assault or criminal offence;
- injuries sustained while operating a motor vehicle, either while under the influence of any intoxicant or if the covered person’s blood contained more than 80 milligrams of alcohol per 100 millitres of blood at the time of injury’
- charges for periodic check-ups, broken appointments, third party examinations, travel for health purposes, or completion of claim forms;
- charges for services or supplies:
- when there would have been no charge at all in the absence of plan benefit coverage;
- when reimbursement would have been made under a government-sponsored plan in the absence of plan benefit coverage;
- which are received from a medical or dental department maintained by an employer, association or trade union;
- which are required for recreation or sports but which are not Medically Necessary for regular activities;
- which would have been payable by the Provincial Plan if proper application had been made;
- which are performed or provided by the covered person, an Immediate Family Member or a person who lives with the covered person;
- which are provided while confined in a Hospital or an in-patient basis;
- which are not specified as a Covered Expense under this Benefit;
- medical or surgical care which is cosmetic;
- medical treatment which is not usual and customary, or which is Experimental or Investigational in nature.
All purchases and acquisition of services must be made in Canada. The only exception is the online purchase of glasses or contact lenses.
Manulife Plan Member Secure Site
Health Plan members must be registered on the Manulife Plan Member Secure Site and signed up for direct deposit to use eClaims and provider electronic submit. Service Providers must be registered with Telus Health for provider electronic submit.
Health Plan members must be registered to access Health eLinks and the My drug plan look-up tool.
- Go to manulife.ca/planmember click on “Login/register” and you’ll be directed to the site access page.
- On the site access page, click on “register” and provide the required information. (If you’re not sure of your plan and certificate numbers, check your Manulife group coverage benefit card or find the numbers on a previous claims statement).
- Submit the completed information and follow the directions on the page.
My drug plan…electronic drug look-up
An electronic drug look-up tool, “My drug plan” is available though the Manulife Plan Member Secure Website. My drug plan answers questions like: Is my prescription covered? How much does my plan pay? How much do I pay? Is there a lower cost alternative? Does it need to be approved by Manulife before I buy it? It also includes resources like a drug library and provincial drug program information, plus easy access to Manulife’s drug prior authorization forms. You must be registered on the Manulife plan member site www.manulife.ca/planmember to access the drug look-up tool.
Health eLinks offers direct access to a complete library of health-related information and resources, in addition to providing a Health Risk Assessment (HRA) that can identify up to 13 different health concerns. Powered by MediResource Inc., a leading provider of interactive health information, tools and technology, Health eLinks connects you to resources that can help you better understand and improve your overall health and well-being.
Health eLinks delivers:
Health risk assessment (HRA):This interactive questionnaire helps you evaluate your current health and identify potential health risks.
Health libraries: Health elinks is your one-stop resource to online health libraries with information on medical conditions, medications, and tests and procedures. You’ll find health articles featuring a wide range of topics. You’ll find a Community Resource Centre which helps identify supportive resources within your community, along with a Health Centre that compiles information related to a particular health issue.
Personal health improvement: Once you’ve completed both the HRA and a risk profile, what’s next? Start taking action! Put a personal health improvement plan together.
You have to be registered on Manulife’s Plan Member Secure Internet site, to access Health
How do I make a claim?
You typically do not have to submit claims for prescription drugs. You need to present your pharmacist with your benefit card to pay your "co-pay" amount at the pharmacy. The pharmacy submits for the remainder of the claim.
For prescription drug claims not processed by the pharmacy, you can electronic submit or submit a paper claim.
Many paramedical practitioners (for example, acupuncturist, chiropractor, massage therapist, naturopath, physiotherapist) are set up with Provider eClaims. With this process, providers are able to submit claims directly to Manulife on your behalf. You only pay the provider the $10.00 fee (where applicable) plus what the plan doesn’t cover.
You, the plan member must be registered on the Manulife Plan Member Secure Website and signed up for direct deposit and electronic claims statements.
If your provider is not registered please direct them to Manulife for details on setting up with the Telus network.
For paramedical practitioner claims not submitted by the provider, you can electronic submit or submit a paper claim.
Plan Member Electronic Submit:
You can submit claims electronically for claims not directly submitted by the pharmacy or paramedical practitioners, for those other medical claims that require a claim form.
- Vision Care: You must bring a Manulife Group Benefits Vision Claim Form #51, when you visit your provider. The lenses/frames and contact lenses, additional medically necessary eye exams and other vision benefits require a claim form be completed.
- Clinical Measurements: complete a Manulife Clinical Measurements Claim Form #53
- Extended Health Claim: for other medical services/supplies/equipment complete a Manulife Extended Health Claim Form #67.
You can select “other” to submit claims for:
- medical equipment and supplies
- hospital expenses
- ambulance expenses
- diagnostic fees
- emergency expenses from outside province
- expenses from any healthcare service provider not listed
Upload: You can scan and upload claim forms and receipts when submitting online, or take a picture and attach it with Manulife Mobile.
Login at www.manulife.ca/planmember
, select Claims from the top navigation and then Online claims. Enter the details of your claim found on the receipt from your provider along with your provider’s name, address and contact information.
If you do not have the means to make a claim electronically, you can submit paper claims.
Mail your Health claim form to Manulife along with your receipts within 18 months of date of service. Write your name, policy number and plan member certificate number on all the receipts. Mail to the address on the claim form.
Plan members in Halifax, may drop-off claims at the Manulife drop-off box located at the Manulife Security Desk, 2727 Joseph Howe Drive, Halifax.
What if my spouse also has coverage?
Canadian insurance companies follow a process called Coordination of Benefits (CoB) when a plan member is covered under more than one health and/or dental plan. CoB ensures you receive the maximum benefit available from your policies. In fact, two policies can be combined to give you up to 100% reimbursement of eligible claims.
When you are covered under your plan and under a spouse’s plan, here's how Coordination of Benefits works:
1. Submit your expenses first to your benefits plan. You can then submit any unpaid portion of your claim to your spouse’s plan.
2. Submit your spouse’s expenses first to your spouse’s benefits plan. You can then submit any unpaid portion of your spouse’s claim to your plan.
3. If your dependent children are covered under your and your spouse’s benefit plans, you must submit all their claims first to the benefit plan of the parent whose birth date falls earliest in the calendar year (the month, then day). Any remaining balance can then be reimbursed from the other plan. When parents are separated or divorced, the custodial parent claims under his or her plan first, then their spouse’s plan (where applicable), then the plan of the parent without custody, and then their spouse’s plan.
4. When you submit a claim for an unpaid balance from another insurance company, you plan will need a copy of the receipt and a copy of the statement (Explanation of Benefits E0B) showing the portion of the claim paid by the other company. Although you have 18 months to claim any remaining balances, your receipts should be submitted as soon as possible.
If you need help determining the order claims should be submitted, call the Manulife Customer Service Centre toll-free at 1-855-626-4267.
If you are covered by more than one plan, please call Health Association Nova Scotia toll-free at 1-866-886-7246 regarding any changes or updates to your Coordination of Benefits information.
CONTINUATION OF COVERAGE
What happens during a leave of absence?
If you take an approved paid leave of absence, you must continue coverage for up to 12 months.
If you take an approved unpaid leave of absence, you may continue for up to 12 months. If you take an approved maternity or parental leave, you may continue for the duration of the leave. If you choose not to continue the benefit during your leave, coverage is reinstated on your return to work.
If you are on an approved sick leave, or approved for benefit for your employer sponsored Long Term Disability plan you may continue benefits.
For cost sharing arrangements, please check your collective agreement or contact your employer for more details.
What happens If I lose coverage under another plan?
If you had opted-out of the health plan because you were covered under another plan, you may join the HANS Health and/or Dental plan within 60 days of losing the coverage. To be approved for coverage after 60 days you will be required to provide medical evidence of insurability.
What happens to coverage when I turn age 65?
Your coverage does not change. We do recommend you contact Nova Scotia Seniors’ Pharmacare Program when you turn 65 and notify them you have drug coverage under your employers group plan. If eligible, this will assist with a smooth transition to the Seniors’ Pharmacare program when you are no longer covered for prescription drugs under this plan.
What happens to coverage when I turn age 70.
Your prescription drug coverage ceases. Your premiums may be lower. In advance of losing drug coverage under our plan, you should contact the Nova Scotia Senior’s Pharmacare Program at 902-429-6565 or toll free at 1-800-544-6191 for more information.
What happens to coverage if I die before retirement?
In the event of your death before retirement, your eligible spouse and eligible dependent children may continue their coverage for up to 24 months after your death. No premiums are required for this coverage.
What happens to my coverage when I retire?
You are eligible for retiree benefits if you have at least 10 years of continuous service immediately prior to retirement and receive a pension from the Nova Scotia Health Employees’ Pension Plan (NSHEPP) or if not a member of NSHEPP, the pension plan sponsored by your employer. Please contact your Benefits Administrator for more clarification. Prescription drug coverage under retiree health plans cease at age 65. If you are a resident of Nova Scotia you may be eligible for Nova Scotia Seniors’ Pharmacare Program, effective 1st day of 65th Birthday month. You can contact the Nova Scotia Senior’s Pharmacare Program at 902-429-6565 or toll free at 1-800-544-6191 for more information.
Can I convert my coverage?
You may choose to convert your coverage to an individual policy within 60 days of your coverage ending.
Call the Manulife Customer Service Centre toll-free at 1-855-626-4267 for options.
Emergency Travel Coverage
Members of the Health Association Nova Scotia Health Plan (and families of those with family coverage) are covered in case of a medical emergency on a trip outside your province of residence or outside Canada. Travel Coverage ceases at retirement. A medical emergency means it is unexpected and not preplanned.
Emergency Travel Assistance is insured by SSQ Insurance Company in collaboration with AXA Assistance. Maximum coverage is $2,000,000. It covers eligible emergency medical expenses and provides additional benefits when you and/or your family members travel for 60 days or less per trip. Plan members (not spouses or dependent children) may be eligible for 180 days of coverage if the trip is for business purposes and is approved by the insurer.
Travel claims must be submitted within 30 days of the occurrence.