Eligible expenses

Drugs covered by the Concordia Health Plan
The following drugs are eligible for reimbursement under the plan:

• Drugs for treatment of an illness or injury, prescribed by a physician or dental surgeon, and dispensed by a pharmacist, including those for the treatment of cardiac problems, pulmonary problems, blood stream disorders (blood clot), cholesterol,digestive problems, infected wounds (cutaneous ulcer), diabetes, arthritis, Parkinson’s disease, epilepsy, cystic fibrosis, glaucoma and hyperthyroidism. Homeopathic preparations are not covered.
• Compounded drugs, where one of the ingredients is an eligible drug expense.
• Oral contraceptives prescribed by a physician.
• Injectable drugs and vitamins, allergy extracts, serums and vaccines prescribed by a physician for preventing or treating an illness. Preventive vaccines are limited to a payable amount of $100 per benefit year per insured person.
• Sclerosing injections used in the treatment of varicosities, when this treatment is primarily for therapeutic and not cosmetic purposes, up to a payable amount of $20 per visit per insured person.
• Anaesthetic administered during surgery outside a hospital, to a maximum of $50 per day for each insured person.
• Reagent strips and syringes for the treatment of diabetes.
• Smoking-cessation products or drugs that appear on the formulary of the Régie de l’assurance-maladie du Québec (RAMQ), in excess of the amount covered by the RAMQ, to a maximum of $600.

This plan covers these different types of drugs at different levels. It all depends on where the drug fits into the following table. This table applies to all eligible employees and pensioners, whether or not they reside in Québec.

Is the drug you are purchasing on the formulary of the Régie de l’assurance-maladie du Québec (RAMQ)?

Please note:

• All covered drugs must legally require that a prescription be issued.
• The medical experts at RAMQ determine which drugs are "appropriate" for coverage under its formulary. These experts also determine whether, and to what extent, new drug therapies should be covered. Should you have any questions about this, please contact the RAMQ directly.
• The plan automatically covers new drugs approved for use by Health Canada and the corresponding provincial health agencies, unless specifically excluded by Concordia or Desjardins Financial Security.

If you live in Québec, once you reach age 65, you automatically become covered under the drug plan of the Régie de l’assurance-maladie du Québec (RAMQ).

By law, you have the choice to remain covered under the RAMQ drug plan or to receive equivalent RAMQ drug coverage under the Concordia Health Plan.

When you are covered under the RAMQ drug plan:

• you and your insured eligible dependents remain in the Concordia Health Plan for coverage relating to non-RAMQ drugs and other eligible expenses;
• your dependents must be covered by the RAMQ plan for RAMQ drugs;
• the RAMQ plan is the primary payer for RAMQ drugs; and
• you can submit a claim to the Concordia Health Plan for amounts not reimbursed by the RAMQ plan. In fact, when you use the direct-payment drug card, the plan covers the difference between your coverage under the RAMQ plan and what the Concordia Health Plan would have paid had you not been participating in the RAMQ plan. As a result, your reimbursement from both plans combined is equal to what employees and pensioners under age 65 would get under the Concordia Health Plan.

To date, all individuals eligible for the RAMQ drug plan participate in it because of its cost effectiveness. Benefits Services will assume that you will remain covered under the RAMQ drug plan, unless:

• you provide instructions to the contrary; and
• you pay the additional, required premiums.

When illness, accidents or other emergencies occur while travelling outside your province of residence, it’s good to know that you and your insured eligible dependents can count on a special feature of the Concordia Health Plan—an assistance program for medical emergencies.

To be insured for this benefit, you and your eligible dependents must have provincial health care coverage. Expenses for hospital, medical and paramedical services as well as travel assistance benefits are eligible if they are:

• incurred as a result of an accident or illness that occurs while travelling outside your province of residence during the first 180 days of a trip;
• included in the list of eligible expenses under the plan; and
• not payable by a government body or under another private insurance plan.

The overall lifetime maximum reimbursement of eligible expenses for emergency care and travel assistance outside your province is $1,000,000 per insured person.

All payments will be made in Canadian dollars.

The plan does not cover any expenses incurred by you or your insured dependents on a non-emergency or referral basis, while outside your province of residence.

Other special exclusions and limitations also apply.

• Hospitalization for necessary treatment. You must contact Sigma Assistel as soon as you or an insured dependent is hospitalized; otherwise, certain expenses may not be reimbursed. If the hospital expenses are incurred in Canada, they are limited to the amount provided for in the Concordia Health Plan.

  If you are a pensioner
  You and your insured eligible dependents must return to your province of residence for at least 30 consecutive days before becoming eligible for another 180 days of coverage.

  

  If you intend to leave the province while on University business or on sabbatical leave, you may be covered under the plan for up to 2 years.

  Contact Benefit Services for information before you travel.

• Services of physicians, surgeons and anaesthetists
• Transportation for the patientto his or her place of residence to receive care as soon as possible, provided the means of transportation originally arranged for the return trip cannot be used. Sigma Assistel must approve and arrange the trip by a suitable means of public transportation. Furthermore, if Sigma Assistel recommends that the patient return home and he or she declines, travel assistance coverage will end.
• All other eligible expenses covered under the Concordia Health Plan in your normal province of residence, excluding hospital and convalescent care.

• Family assistance benefits, which include reimbursement of the cost of:
  • Transportation
    • Transportation for an immediate family member (who is covered under the Concordia Health Plan) at the same time as the patient travels as described under Transportation for the patient, provided the means of transportation originally arranged for the return trip cannot be used. Sigma Assistel must approve and arrange the trip.
    • Round-trip economy transportation for a qualified medical attendant who is not a family member, a friend, or a travelling companion, provided the presence of this attendant is ordered by the attending physician and approved by Sigma Assistel.
    • Round-trip economy transportation (by plane, bus or train) for one immediate family member if you or an insured dependent is hospitalized for at least seven days. Expenses will be reimbursed only if no immediate family member aged 18 or over is present and the attending physician considers the visit beneficial to you. Sigma Assistel must give prior approval. These expenses are also covered when it is necessary for an immediate family member to identify a deceased family member before the release of his or her body.
  • Daily allowance
    • The cost of meals and accommodation for you or an insured dependent who must delay returning home because of an illness or bodily injury suffered by that person, an accompanying immediate family member or a travelling companion, as well as additional child care expenses for dependent children not on the trip.
      The maximum daily living allowance payable is $150 per day per insured person for a maximum of seven days. A physician must certify the illness or injury.
    • Long-distance telephone charges to reach an immediate family member if you or an insured eligible dependent is hospitalized, provided that the transportation allowance is not used and the patient is not accompanied by an immediate family member aged 18 or over.
      The maximum amount payable for long-distance charges is $50 per day, up to $200 per period of hospitalization.
  • Return of a vehicle
    • (personal or rented) if you or an insured dependent suffers from a disability as a result of an emergency, certified by a physician, that prevents the operation of this vehicle and none of the accompanying immediate family members are able to return it. A commercial agency may be hired to return the vehicle, but the return must be arranged and approved by Sigma Assistel.
      The maximum amount payable for returning the vehicle is $1,000.
  • Return of the remains
    • f you or an insured dependent should die. This includes the costs of preparation and the return of the body or ashes to the place of residence by the most direct route (by plane, bus or train). The cost of the burial coffin is not covered. The return must be pre-approved and arranged by Sigma Assistel.
      The maximum amount payable for preparation and return of the deceased is $5,000.

The plan brings to your aid a worldwide communications and health care network—24 hours a day, seven days a week—through Sigma Assistel, a company specializing in emergency medical assistance for travellers.

In the event of a medical emergency, contact Sigma Assistel immediately:

The 24-hour help-line can assist you and your insured eligible dependents with:

• referral to physicians or health-care facilities;
• assistance for hospital admission;
• cash advances to the hospital when required by the facility;
• trips home, when health permits it;
• establishing and staying in contact with the insurer;
• handling arrangements in the event of death;
• repatriation of dependent children, if you or your insured eligible dependents cannot be moved;
• delivery of medical assistance and drugs to you or your insured eligible dependents who are too far from health care facilities to be transported there;
• arrangements to bring an immediate family member to the insured person’s bedside, provided that he or she must be hospitalized for at least seven days and the attending physician orders the visit;
• assistance in replacing lost or stolen identification papers so that you or your insured eligible dependents can continue travelling;
• referral to lawyers if legal problems arise;
• translation services for emergency calls;
• transmission of urgent messages to close friends or family in case of emergency; and
• information prior to departure concerning passports, visas and vaccinations required in the country of destination.

When calling the 24-hour help-line, please be ready to state your Policy Number and Member ID located on your Desjardins Financial Security travel assistance certificate. Also be prepared to provide the Provincial Medical Insurance Plan/Health Card Number of the family member who has the medical emergency. We need these numbers in order to process your claim.

Neither Concordia, Sigma Assistel nor Desjardins Financial Security is responsible for the availability or quality of medical treatment or services received by you or an insured eligible dependent.

• Semiprivate room
  The cost for a semiprivate room in:
  • a public general hospital that exceeds the amount covered by the provincial health plan (or the same amount toward the cost of a private room), plus any user fees the hospital may charge, where permitted by law; or
  • a licensed convalescent hospital. The maximum stay is 60 days for all admissions per benefit year. The insured person must be admitted within 14 days after being discharged from a hospital where he or she was an inpatient.
• Standard ward
  In case of hospitalization in Canada, the portion of standard ward accommodation that is not covered by your provincial medical plan, if any.

Coverage is provided for acute care, for an unlimited stay.

The maximum reimbursement for all eligible vision care expenses is $160 per person per 24-month period (12-month period for children under age 18).

The provincial health plan will cover eye exams for those under age 18 and those age 65 and over.