Benefit plan terms make your head spin? We get that.
We’ll help you understand your benefits, so you can make the most of them.
Choose from this list of exciting topics (well, to us they are exciting) for explanations of common benefits plan terms.
Acute care drugs are used to treat one-time or short-term conditions. Maintenance medications are used to treat chronic or long-term conditions.
Speak to your pharmacist or physician about the quantity of drugs you’ve been prescribed. He or she can recommend a larger supply of any drugs that fall into the maintenance drug category (after the initial days supply is satisfied).
Getting a larger supply of maintenance drugs can reduce your dispensing fees and save you extra visits to the pharmacy.
Drugs used to fight infections caused by bacteria, and that aren’t effective in working against viruses.
Bacteria may change over time and become resistant. Taking antibiotics unnecessarily, too often, or not finishing your prescribed dosage can lead to more resistant bacteria. Always complete your full prescription and do not save part of it to use another time. Follow the prescribed instructions; if they aren’t clear or you’re unsure, ask your doctor or pharmacist to explain. Never use antibiotics that were prescribed for someone else.
Generic drugs contain the same active medicinal ingredients (the stuff that actually makes you better) as the corresponding brand name, and are therefore considered therapeutic equivalents. However, substances combining the active ingredients may be different.
In Canada, generic drugs are strictly regulated and must meet certain clinical standards to be substituted by the pharmacist.
For the most part, generic products cost less and can reduce the costs of your health plan. Ask your health care professional to prescribe the generic drug whenever possible.
You pay a portion of the cost of your prescriptions by paying either the same amount each time (e.g. $5) or a percentage of the total cost (e.g. 20%). If you’re paying a percentage, then you’re encouraged to shop around for the best available dispensing fees and ingredient costs.
Some plans require that you pay a fixed amount each year before your coverage starts (e.g. first $100 of prescription costs).
Some drug plans cap (or limit) the amount you’ll be reimbursed for any dispensing fees. In that case, a fixed amount is paid toward the professional dispensing fee charged on every prescription. As the plan member, you would be required to pay any difference between the capped fee and the dispensing fee.
The total cost of a drug to you or your drug plan is made up of a number of components:
- Pharmacy dispensing fee (see above)
- Ingredient/manufacturer cost – the sale price charged by the manufacturer for the drug
- Wholesale mark-up – the amount added on to the manufacturer’s sale price by the wholesaler
- Pharmacy mark-up – the amount added on to the manufacturer and/or wholesaler price by the pharmacy
Drug pricing varies by pharmacy, region and province. It can also sometimes vary depending on whether you pay the pharmacy out of your own pocket, or use your GSC ID card to only pay the portion not covered by your benefit plan. It’s okay to shop around for the best pricing.
A DIN is assigned to a drug product by Health Canada before it reaches the market. The eight-digit number tells you the product has been approved for use and can legally be manufactured and sold in Canada.
A DUR occurs when you fill a prescription at the pharmacy (as long as you have a pay-direct drug plan). It’s a real-time system review of the current prescription and your historical claims profile, done while you are waiting for your prescription to be filled. Within five seconds, and before the drug is dispensed, we can notify the pharmacy of any drug-to-drug interactions, pharmacy hopping, double doctoring, duplicate therapies or duplicate ingredients, or prescriptions being filled too soon or too late. If a potential health hazard is identified, we’ll send a warning to the pharmacist, who will in turn evaluate the response. He/she may contact your physician or provide advice. A DUR ensures drug therapy compliance, as it helps to ensure medication is taken as prescribed. It improves health awareness by promoting consumer education, increases your health safety and may reduce the overall cost of benefits.
A list of drugs covered as benefits through your provincial health plan, your group plan or your individual plan. Each drug plan determines its own list of covered drugs.
When a new prescription is dispensed in a smaller amount to start (e.g. 30 days). This helps prevent wastage of costly medications in the event that you suffer from drug intolerance or want to change your prescription before you’ve finished taking all the pills originally prescribed.
Often called “complementary” or “alternative” medicines, NHPs are substances used to restore or maintain good health. Natural substances include: vitamins and minerals, herbal remedies, homeopathic medicines, traditional medicines, probiotics, and other products like amino acids and essential fatty acids. Some natural health products were once identified by Health Canada with DINs, but have since been reclassified as NHPs. Because they no longer have a DIN, they are not eligible for coverage on GSC drug plans unless stated otherwise in your benefit booklet.
GSC’s Preferred Pharmacy Network (PPN) consists of a wide range of pharmacies across Canada and includes a variety of high-cost specialty drugs. Plan members who receive prior approval for a specialty drug included in the program are automatically enrolled in the PPN and receive preferred pricing from their selected network pharmacy and personalized support from GSC’s partner, HealthForward.
A drug prescriber must be a physician or other licensed health care practitioner with the authority to prescribe within the scope of their practice in their province.
These are drugs that have a drug identification number (DIN), and by law, require a prescription for sale and are provided to the public by a pharmacist after the diagnosis and professional intervention of a health care practitioner. Examples: Penicillin, Imitrex, Ventolin, and Tylenol #3.
Some drug plans only cover certain medications for specific medical conditions. In these cases, prior approval is required. Your doctor may need to fill out a special authorization form for these types of medications before your plan will pay for the drug.
A professional (or dispensing) fee is the amount a pharmacy charges for providing professional services such as patient counseling, monitoring drug therapy, providing drug information to physicians and dispensing drug products. It also covers stocking of medication and maintaining patient medication records. Dispensing fees can differ from pharmacy to pharmacy, making a big difference in the total cost of the prescription. If you are not happy with the dispensing fee that your pharmacy charges, it’s okay to shop around to find a better price. (In Ontario, pharmacies are required to post their average dispensing fee so it’s visible to all customers.)
One of the key differences between traditional medications and biologics is in how each is manufactured. Traditional drugs are chemically synthesized in a process fairly easily replicated—think of these as recipe-based products. Biologics are derived from living cells, tissue or micro-organisms using much more complex, highly controlled manufacturing processes that are unique to each drug. They are more expensive to research, manufacture, store and deliver than pharmaceuticals—and, as a result, can cost much more. According to GSC’s administrative guidelines (these are the rules that guide how we pay claims), all plans default to covering the most therapeutically and cost-effective drug within a class first, allowing you to move on to other drug in the class only when you experience an undesired response to the first drug.
BASIC DENTAL COVERAGE TERMS
Extractions (literally, pulling teeth), including simple and complicated removal of erupted teeth, partially or completely bone impacted teeth, extra teeth in an unusual position, or residual roots.
An X-ray taken from the side to show the crown area (top) of both the upper and lower teeth.
During a dental checkup or recall exam, your dentist is trained to look for oral health problems that you can’t always see or feel – problems like deteriorating fillings, early signs of gum disease or oral cancer, and others that could affect your general health.
A material is placed in the pits and fissures of teeth to prevent or stop the development of dental caries (tooth decay). This treatment can only be used on permanent molars (back teeth) of children under 16 years old.
Maintenance exams performed once a year following the initial oral examination. They help to prevent tooth decay, gum disease and other dental disorders that could have developed over the year. A recall visit typically includes an exam, as well as:
- Polishing: Smoothing the tooth surface to make it difficult for plaque to accumulate on the surface area.
- Scaling: Removal of dental plaque /calculus from the surface of a tooth.
Ortho-like appliance used on children’s teeth to keep the space open to allow the permanent tooth to come in properly.
“COMPREHENSIVE BASIC” DENTAL TERMS
An appliance that helps prevent involuntary gnashing, grinding or clenching of the teeth.
May include surgical exposure movement, remodeling and re-contouring, surgical excision (removal), surgical incision, treatment of fractures and some maxillofacial (jaws and face) deformities such as cysts and tumours.
Removal of calcium deposits (plaque, tartar, calculus, and stone) from around the tooth above and below the gum.
Also known as endodontic or having the nerve removed. It’s the removal of infected pulp (abscess/pus) from within the crown and root mechanically, with files and reamers (cutting tools). After mechanical and medicinal cleaning, the root canal is filled and sealed.
A splint to correctly balance the position of the lower jaw to the skull. This is used to treat TMJ syndrome – acute muscle spasms believed to be caused by biting imbalance that can be induced by psychological stress. Principle symptoms are pain in the ear region, limitation of chewing and moving the jaw, and clicking, cracking, ringing, or buzzing sounds in the joint.
MAJOR DENTAL SERVICES TERMS
A custom device anchored to neighboring teeth that replaces one or more missing teeth. When a lost tooth is replaced with a bridge, the teeth on either side of the missing one must be prepared as crowns to serve as supports to hold the prosthetic (replacement) teeth in place. This procedure is necessary when a permanent tooth is lost; whether as a result of decay, gum disease, injury or accident, which can cause many serious problems for your neighboring teeth (they may begin to shift).
A tooth-like covering placed over a carefully prepared existing tooth. It is sometimes called a “cap” and is used to strengthen, restore or improve the appearance of your natural tooth. A crown is placed on an individual tooth much like a thimble over your finger. One of the most common functions is to support the tooth when there is no longer sufficient tooth structure left to place a filling. Crowns may also be used to protect the structure of a tooth that’s fractured or broken.
A dental implant is a titanium cylinder that the dentist surgically places into the bone where a tooth is missing to become the foundation for a replacement tooth. The dentist either screws the replacement tooth into the implant and cements crowns or bridges into the implant, or uses special attachments on the implant to attach a removable denture.
ORTHODONTIC (BRACES) TERMS
A cosmetic substitute to the conventional metal braces. Clear brackets, made of ceramic or plastic, blend in more with the tooth’s natural colour.
These braces are gold-coated stainless steel, often recommended for patients who are allergic to nickel or prefer the look of gold over traditional silver-coloured metal.
Clear removable aligners used to gradually shift teeth to the desired positions. Typically, progressive braces aren’t used in complex orthodontic cases.
OTHER DENTAL STUFF
A policy applied to all coverage that includes crown and/or bridge treatment, to determine the amount payable. The attending dentist and patient choose the course of treatment, but payment for the procedure may be based on the "limited treatment" principle. Basically, if two procedures treat the same condition, payment may be limited to the most cost-effective treatment. The Alternate Benefit Clause is simply a financial limitation and not intended to dissuade from the treatment recommended or performed by a dentist. In the application of this, both courses of treatment must be an eligible benefit.
When multiple fillings or periodontal (gum) services are done at one appointment, there may be a reduction in time spent by the dentist and therefore the benefit should be passed along to the patient in the form of reduced fees. It applies only when six or more restorations (fillings) are done in the same appointment. And if the dentist has not reduced the fee for these multiple services, we will reimburse the first restoration as submitted, according to the dental plan, and then reduce the remaining restorations by 20%.
EXTENDED HEALTH BENEFITS
Reimbursement for the services of a licensed dental practitioner for dental care when required by a direct blow to the mouth and not by an object consciously or unconsciously placed in the mouth. The accident must occur while the coverage is in force. You must notify GSC immediately following the accident and the treatment must commence within the timeframe indicated in your benefit booklet.
A hearing aid is a small electronic device that can be worn in or behind the ear. It consists of three basic parts: a microphone, amplifier and speaker. A hearing aid may be required if an audio specialist has determined that you have a loss of hearing acuity. To determine specific benefit coverage based on your individual plan design, contact our customer service center.
Custom shoes are prescribed when your needs cannot be accommodated by regular (or modified) orthopedic footwear due to the severity of your foot condition. This includes structural deformities from congenital systemic disease, arthritic disease, traumatic foot injury, asymmetry or aging, or postsurgical amputations.
The construction of custom shoes requires a high degree of specialized expertise from the provider. You must go to an authorized provider who will assess your condition, create a cast of your feet, and have the custom footwear manufactured from scratch using raw materials.
A professional land or air ambulance to the nearest hospital equipped to provide the required treatment, when medically required as a result of an injury, illness or acute physical disability.
A home care benefit provides coverage for the services of a Registered Nurse, or a Registered Practical Nurse on some plans, in the home. These services are only a benefit when medically necessary and only when the services required cannot be performed by someone with lesser qualifications. Various plans may have the added benefit of a Personal Support Worker. Pre-approval with GSC is required for this benefit.
- Private –A private room with one bed in a public general hospital.
- Semi-Private –A room with no more than two beds, sharing one bathroom.
- Ward –A room with three or more beds in a public general hospital.
On discharge, remember to ask to see a copy of the accommodation charges to verify that they are charging you for exactly what you received. Your hospital may send a claim directly to GSC as semi-private, without verifying the room type you actually received. If your doctor requests a private or semi-private room (preferred accommodation) for you for medical reasons, neither you nor GSC should be billed for these room charges. Your Provincial Health Insurance Plan will cover this benefit. GSC will only pay for preferred accommodation (a private or semi-private room) upon patient choice and provided the patient has signed a request for such accommodation. You should also not be charged for ward accommodations (three or more beds in a room), ICU (Intensive Care Unit) beds, CCU (Critical Care Unit) beds, or outpatient beds for day surgery. When a mother and her newborn occupy the same room, only one claim should be billed.
Medical items that are medically necessary to assist with mobility, or to help correct a medical condition may be eligible through a benefit plan. Items that are not primarily medical in nature or for comfort and convenience are not eligible. A physician’s authorization may be required for various medical items, and specific medical items may require pre-approval. GSC does not reimburse claims for used medical equipment.
Orthopedic footwear accommodates, controls or supports the therapeutic needs of a foot deformity or abnormality in the leg, knee, or ankle, and must be manufactured by recognized and reputable orthopedic footwear manufacturers. The footwear may be modified or adjusted to fit your feet.
Orthopedic footwear may be prescribed for bone deformities, neurological conditions such as multiple sclerosis, osteoarthritis, and foot complications caused by diabetes.
If you are prescribed orthopedic footwear, you must go to an authorized provider trained to assess, design, modify, and fit orthopedic footwear.
Information about GSC’s orthotics and orthopedic shoe policy can be found in our FAQ.
A custom orthotic is a removable foot-care device worn inside a shoe and made from a three-dimensional cast impression of your foot. It must be constructed from raw materials based on your individual specifications. Orthotics are intended to support, align, prevent and/or accommodate foot abnormalities and improve how the foot functions.
Orthotics are prescribed to treat diagnosed medical conditions such as structural weaknesses or deformities, traumatic injuries, overuse syndromes, and complications from diseases such as diabetes.
If you are prescribed custom orthotics, you must buy them from an authorized provider trained to assess, design, manufacture, and fit orthotics.
Information about GSC’s orthotics and orthopedic shoe policy can be found in our FAQ and Glossary.
The following is a list of some of the more common paramedical practitioners (health care professionals) and their related health professional services. A physician’s authorization may be required on the initial claim. GSC requires that a paramedical practitioner be licensed in the province in which they are practicing.
- Acupuncturist –A natural form of Chinese medicine which involves inserting needles into a patient’s skin at specific areas of the body, to concentrate on the points in need of healing. Acupuncture is used to improve a patient’s mood or energy levels, relieve pain, and restore function of the affected areas.
- Chiropodist – Chiropodists assess and treat disorders of the foot including deformities, skin lesions, corns, calluses and warts, and nail conditions.
- Chiropractor –Medical professionals trained to diagnose and treat conditions related to the spine and other body joints, by manipulating and correcting the alignment of the spinal column. They primarily treat disorders related to the back, neck and head pain. Chiropractors also counsel patients on corrective exercises and nutrition.
- Dietitian –Certified health professionals who can provide advice on nutrition, food, and healthy eating choices. The term nutritionist is not interchangeable with dietitian – although all dietitians are nutritionists, not all nutritionists are certified dietitians.
- Massage Therapist – A massage therapist manipulates the soft tissues of the body in an effort to relieve muscle tension and discomfort. Registered massage therapists (RMT) use their in-depth knowledge of anatomy, physiology, and pathology to adjust the soft tissue to break the pain cycle and bring about results. Massage therapy can help give patients relief from muscle spasms, tension in the neck and back, tired hands and feet, headaches, sports injuries, etc.
- Naturopath – Naturopathic medicine combines modern scientific health knowledge with traditional and natural remedies. The naturopathic philosophy is to treat the underlying cause of a disease. Symptoms are viewed as warning signals of malfunctions within the body and poor lifestyle habits. Many people visit a naturopath on a regular basis to find out how to maintain good health. Naturopaths help manage patient concerns on a variety of health issues, from allergies and digestive problems to depression and more serious illnesses. Supplements and remedies are not eligible benefits under any GSC plan.
- Osteopath –Treats diseases by manipulation of the bones. Osteopathy is based on the theory that the body will produce the remedies necessary to protect itself as long as the bones are aligned properly and do not press on the nerves. Osteopaths treat patients using a combination of gentle stretching, massage, and mobilizing joints to ease symptoms. Commonly, patients visit an osteopath to seek relief from back pain, stiff joints, headaches, arthritis, fatigue, or digestive issues.
- Physiotherapist – Physiotherapists use a combination of comprehensive knowledge of how the body works and practical clinical skills to diagnose and treat injuries and illness. They work towards maximizing patient strength, mobility and well-being. A physiotherapist prescribes customized exercises and educates patients on essential steps to recovery.
- Podiatrist –A specialized medical field that centres around the study and care of the foot and ankle. A podiatrist focuses on preventing, diagnosing, and treating conditions of this area by medical, surgical, and other means.
- Psychologist – Psychology is the scientific study of the human mind and its functions. Psychologists provide counseling and psychotherapy for patients seeking treatment for life adjustment problems, behavioural issues, emotional disorders, or mental illness. They provide treatment for individuals of all ages as well as for families or groups.
- Speech Therapist – Speech therapists work to prevent, identify, and treat communication and swallowing disorders as well as counsel patients and their families on their conditions. Speech therapists assess each patient’s individual needs and implement custom speech and language programs in an effort to help develop effective communication.
This is the “reasonable” reimbursement amount determined by GSC for a medical item or service. GSC establishes reasonable and customary pricing for all covered health services and major medical equipment. We determine our reasonable and customary pricing based on reviewing rendered amounts, manufacturers’ pricing and provincial and association pricing. In all cases, we reimburse the lesser of either the submitted or the allowed unit cost per device or service, as determined by our reasonable and customary pricing policy (which is reviewed on an annual basis).
Here are some services and products you might come across if you have vision benefits:
- Prescription eyeglasses or contact lenses
- Replacement parts to prescription eye glasses
- Medically necessary contact lenses when the visual acuity cannot be corrected to at least 20/40 in the better eye with conventional eyeglasses
- Plano (non-prescription) sunglasses prescribed by a medical practitioner for the treatment of ophthalmic diseases or conditions
Some plans also allow reimbursement toward laser eye surgery in lieu of vision benefits (at the same benefit level). Laser vision correction is used to correct common vision problems, such as myopia (near sightedness), hyperopia (far-sightedness) and astigmatism (distorted vision when looking at objects in the distance).
HEALTH CARE SPENDING ACCOUNT (HCSA)
Based on your group plan design, your employer deposits a set amount into your HCSA—then you use the funds for whatever eligible expenses are important to you. It’s all about individual choice— so you can enjoy all the flexibility and convenience your HCSA has to offer.
Eligible HCSA expenses include all expenses that qualify for medical expense tax credits under the Canadian Revenue Agency (CRA) Income Tax Guidelines, such as:
- Payments to medical practitioners, hospitals, orthodontics, etc.
- Artificial limbs, aids and other medical equipment
- Eyeglasses and contact lenses
- Rehabilitative therapy
HCSA claims can be submitted online directly to GSC via Plan Member Online Services. It’s quick and easy. Or, if you really want to, you can submit your claim by mail. Just follow these steps:
Call our Customer Service Centre at 1.888.711.1119 to receive a claim form. If you would like a pre-filled personalized form, register for Plan Member Online Services.
- Complete the form and sign in the appropriate spot. Remember to include your GSC ID number (found on your GSC ID card). If the claim is for a dependent, include the dependent’s number (also on your ID card).
- Check that you have also included original receipts and remember to take a photocopy for your records.
- Double-check that you have provided your full mailing address and send the form to the GSC address on the form within twelve months from the date you received the service.
For a list of eligible expenses, click here. You may also wish to refer to the CRA website for list of medical expense tax credits as a guideline for eligible expenses under your HCSA.
PERSONAL SPENDING ACCOUNT (PSA)
Your GSC travel benefits are provided by our partner, Allianz Global Assistance. Through Allianz Global Assistance, you can take advantage of a vast network of medical providers, resources and contacts, all offering quality service, when you travel outside your home province.
If you have travel benefits as part of your overall benefit package, it’s important to know what information you need in the event you need to make an emergency health claim when traveling out of province or country.
Some other important information you should know:
- Review your benefit plan booklet so you are aware of what’s covered under your travel benefits plan.
- Contact GSC Travel Assistance by phone, within 48 hours of commencement of treatment.
- You will be asked to provide your GSC ID Number, which is located on the front of your GSC ID card.
Click here for a look at some FAQs related to travel coverage.
YOUR PROVINCIAL HEALTH PLAN
And we’ll help you find that information.
In each Canadian province and territory, your Ministry of Health provides you with coverage for certain health products and services. Select your province below for a look at what your provincial government has to offer:
- British Columbia
- New Brunswick
- Newfoundland & Labrador
- Northwest Territories
- Nova Scotia
- Prince Edward Island
And check out what they offer online…
Each government also provides resources on the Internet – websites devoted to education and providing current information on many health issues. You can also find useful contact information, including telephone numbers and e-mail addresses so that you can be in touch with the right people to help with your health concerns. These websites also often provide useful links to more health-related information. You can find these websites by clicking on your province above.
Your benefit plan documentation is your best resource
Have a question about benefits covered through your plan? To learn about what your benefit plan covers, we recommend you review the benefit booklet provided by your plan sponsor (i.e. your employer). Try to keep your booklet in an accessible place for easy access and convenient reference. Just so there are no surprises when you visit your health care professional, consult your benefit booklet before your appointment as it outlines benefit maximum allowable amounts, eligibility, and co-pay/deductible amounts (where applicable). However, do not let your benefit plan dictate your treatment plan – your health and wellbeing is the first priority.