Insurance Dictionary & Health Guide

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.

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.

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.)

In Canada, health care is a provincial/territorial responsibility meaning each province/territory has its own set of plans and programs. Additional specialty programs may also be available within each province/territory.

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.

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.

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.

Made for people who are already missing all their teeth, as opposed to an immediate denture (which is made before the teeth are extracted) or over denture (where the root canal-treated remnants of teeth or implants remain under the denture to aid in stability).

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.

The most conventional form of braces that are typically made of stainless steel, sometimes in combination with nickel titanium.

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%.

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.

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.

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.

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).

Your HCSA is a spending account funded by your employer that you can use to pay for health and dental expenses that are not covered by your group benefit plan or your provincial health plan

A spending account funded by your employer that you can use to pay for a range of items not covered by your group benefit plan or provincial health plan.