health

EN | FR

Snapshot of Coverage →

COVERED SERVICES →

ELIGIBLE EXPENSES →

PRESCRIPTION DRUG COVERAGE →

Snapshot of Your Health Coverage

The Flexible Benefits Program supplements your provincial health coverage. Here's a snapshot of the Health coverage offered through the Flexible Benefits Program.

Two coverage options, Basic Health and Enhanced Health (see the side-by-side comparison). You can also opt out, in which case you aren’t covered for any emergency travel or medical-related services that you receive outside the country.
One carrier, GreenShield. GreenShield’s Benefits Booklet provides more details about your coverage. Access your GreenShield Benefits Booklet from the Resource Library on MyBenefits Online, or from:

GreenShield+: Once you log in, go to your name at the top, select Account Settings, select the Coverage tile, and then select Benefits Booklets. You’ll see a link to download your GreenShield Benefits Booklet.
GreenShield+ Plan Member: Once you’re logged into your account from the app, select Coverage, select the Benefits Booklets tab, tap the name of the booklet, and select View Policy. A PDF of your GreenShield Benefits Booklet will launch.

What to consider. When deciding whether to elect the Basic Health or Enhanced Health coverage option, consider the following:

Does a member of your family suffer from a condition that requires prescribed medication?
How much money have you spent on your and/or your dependent's medications, vision care, and/or medical services and supplies in the last two or three years?
Do you also have coverage through your spouse’s program (you may want to consider the coverage offered through your spouse’s program against the coverage offered through the Flexible Benefits Program)?

Both coverage options include prescription drug coverage through GreenShield.

Go to MyBenefits Online to see your current coverage elections (if you’re currently enrolled), and for additional coverage and carrier-related details.

Health coverage options

CONTACT INFO & APPS

GreenShield

GreenShield+ Website
GreenShield+ Plan Member App
Main Phone: 1-888-711-1119
GreenShield+ Plan Member Mobile App: APPLE APP STORE | GOOGLE PLAY

Remember …

If you enrol and then decide to opt out of either the Basic Health or Enhanced Health coverage option during the year due to a qualified life event, you won’t have coverage for the remainder of the calendar year. If you decide to opt out during Annual Enrolment, you won’t have coverage for yourself or your eligible dependents for the following year. If you want to re-join, you’ll need to re-elect a Health coverage option during the next Annual Enrolment (or earlier if you experience a qualified life event).

ABOUT COVERED SERVICES

A service is covered by the Flexible Benefits Program provided the treatment is:

Medically necessary and prescribed by a physician or registered practitioner;
Accepted by the Canadian medical profession;
Not covered under the Provincial Health Insurance Plan;
Proven to be effective; and
Of a form, intensity, frequency, and duration that’s essential to the diagnosis or management of your disease or injury.

See your GreenShield Benefits Booklet for services that are excluded from coverage under the Flexible Benefits Program.

Looking for more details?

You can access more detailed coverage information on MyBenefits Online, as well as the carrier’s provider finder tool on GreenShield+ Plan Member.

ABOUT ELIGIBLE EXPENSES

The Flexible Benefits Program pays benefits for eligible expenses. An eligible expense is based on the Reasonable and Customary (R&C) limit for a covered service.

To determine the R&C limit for a covered service:

GreenShield analyzes the costs that are customarily charged for a particular covered service or supply in your area to treat a medical condition; and
Based on that analysis, GreenShield determines the R&C limit for the covered service.

To show how this works, let’s assume you submit an expense for a covered service that’s less than the R&C limit in your province. The Flexible Benefits Program considers the full amount of your submitted expense as the eligible expense and you and the Flexible Benefits Program pay coinsurance on the total.

Now let’s assume your expense for the covered service is more than the R&C limit. In this scenario, you and the Flexible Benefits Program pay coinsurance on the limited amount (the eligible expense). In addition, you’ll pay the difference in cost between what your provider is charging and the R&C limit.

YOUR GreenShield TRAVEL ASSISTANCE SERVICES

ID CARDS

How to Submit Claims

YOUR PRESCRIPTION DRUG COVERAGE

The Flexible Benefits Program pays benefits for prescription drugs that are:

Prescribed by a legally qualified medical practitioner or dental practitioner as permitted by law;
Legally required to have a prescription and a Drug Identification Number (DIN);
Approved through GreenShield’s drug review process; and
Paid on a pay-direct basis.

If you live outside of Quebec, be sure to inquire about your pharmacist’s dispensing fees as they can vary significantly from one pharmacy to another.

Here are a few more details about how prescription drug coverage works under the Basic Health and Enhanced Health coverage options.

SMARTspend formulary

This approach encourages you to use cost-effective first-line therapies, but at the same time ensures you have access to needed treatments.

For certain conditions, you may be asked to try a “first-line” drug before you move to a more costly “second-line” drug. If you do and then move to the second-line drug, you’ll automatically be approved in most cases. In instances when additional prior authorization is needed, GreenShield can help with the prior authorization process.

About prior authorization

Certain drugs require GreenShield’s prior approval before the Flexible Benefits Program pays benefits for eligible expenses. You can confirm whether your drug requires prior approval:

Online: Via GreenShield+ (under Coverage > Check Coverage)
By Phone: At 1-888-711-1119 (representatives at the GreenShield Customer Contact Centre are available Monday through Friday, 8:30 a.m. to 8:30 p.m., Eastern Time)

Mandatory generic drug substitution

When a generic equivalent drug exists, the Flexible Benefits Program pays benefits for eligible expenses up to the cost of the lowest-priced equivalent drug. If you’ve had a serious medical reaction to at least one generic equivalent drug and your provider indicates that a brand name drug is medically required, your provider must complete and submit an exception form so that GreenShield can assess the medical necessity of your higher-priced non-generic prescribed medication. To do so, submit either of the following to GreenShield (only one form is needed not both):

The Request for Approval of Brand Name Drug form (you can obtain this form by contacting the GreenShield Customer Care Centre); or
The Health Canada Vigilance Adverse Reaction Reporting form (you can obtain this form from the Health Canada website).

GreenShield will review the submitted information and determine whether your prescribed drug will be considered a covered service and eligible for benefits.

If you live in Quebec

You can’t opt out of Health coverage under the Flexible Benefits Program, unless you can confirm that you and your dependents (if applicable) are covered under another plan that provides prescription drug coverage required by the Regie de L’assurance maladie du Quebec (RAMQ).

Please Note: If you elect the Basic Health coverage option, your prescription drug coverage will be administered in a way that’s RAMQ compliant.