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.
- Oxygen.
- 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).
- For insulin dependent plan members:continuous glucose monitoring (CGM) receivers, transmitters or sensors
- 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.
- Durable Medical equipment: rental or, when approved by Medavie Clue Cross, the purchase of:
- manual or electric wheelchair, including cushions and inserts;
- manual or electric hospital bed, including mattress & safety side rails;
- equipment for the administration of oxygen, nebulizer, percussor, suction pump, bi-level positive air pressure (BiPAP), continuous positive airway pressure (CPAP) and ventilator;
- BiPAP and CPAP supplies to a maximum of $150 per calendar year;
- insulin pump for the Treatment of type 1 diabetes;
- compression pump, traction equipment; and
- patient lifter.
- The purchase of durable medical equipment requires pre-approval from Medavie Blue Cross, otherwise it may be ineligible for payment in whole or in part.
- Medical Supplies: includes but not limited to:
- 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.
- 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 employees and dependents under age 21.
- Casted, custom-made orthotics, up to a maximum of $300 per three calendar year for adults, and $400 per one calendar year for employees and dependents under age 21 (recommendation a physician or podiatrist required).
- Allergy serums: Covered 100%. Please note, antihistamines available over the counter are not covered.
- 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.
- 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.
- Weight loss drugs: $5,000 in a calendar year, subject to prior authorization and annual re-qualification.
- Fertility medication: $15,000 lifetime maximum
- Sexual dysfunction: $1,200 in a calendar year
What are the health exceptions?
Exclusions and Limitations
No payment will be made (or payment will be reduced) for:
- services, treatment, articles or supplies that do not fall within the categories of Eligible Expenses listed in this benefit;
- health care covered under any government health care coverage or charges payable under any occupational health and safety board, automobile insurance bureau or other similar law or public plan;
- health care that was covered under any government health care coverage or charges payable under a workers’ compensation board/commission, automobile insurance bureau or other similar law or public plan, when this benefit was issued but has since been modified, suspended or discontinued;
- services, treatment or supplies that the Participant receives free of charge;
- charges that would not have been incurred if no coverage existed;
- services, treatment or supplies that are:
- not Medically Necessary;
- for cosmetic purposes only;
- elective in nature; or
- experimental or investigative.
- all services relating to family planning (unless specifically listed as a covered), including artificial insemination, laboratory fees or other charges incurred in relation to infertility treatment, regardless of whether or not infertility is considered to be an illness;
- services or supplies normally intended for recreation or sports;
- extra supplies that are spares or alternates;
- charges for missed appointments or the completion of forms;
- medical examinations or routine general check-ups;
- Treatment related directly or indirectly to full mouth reconstruction, to correct vertical dimension or TMJ (temporomandibular joint)/myofascial pain dysfunction;
- mileage or delivery charges to or from a Hospital or Health Practitioner; or
- services or expenses incurred as a result of:
- insurrection, war (declared or not), the hostile action of the armed forces of any country or participation in any riot or civil commotion; or
- participation in a criminal act or attempt to commit a criminal act, regardless of whether charges are laid or a conviction is obtained.
