Provincial Health Coverage Guide. As of April 1, 2005 Compiled by Green Shield Canada

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1 As of April 1, 2005 Compiled by Green Shield Canada

2 Ontario Low income seniors are responsible for a $2.00 copayment per prescription. Higher income seniors must satisfy a $100 deductible, followed by a copayment of up to $6.11 per prescription.the Trillium Drug Program is available to all Ontario residents covered by OHIP with high drug costs in relation to their income. Eligibility requires that private insurance does not cover 100% of prescription drug costs. Beneficiaries are responsible for an income-based deductible, followed by a copayment of up to $2.00 per prescription.the drug plan includes a Limited Use program under which certain drugs are eligible only under specific clinical criteria, as well as an Individual Clinical Review (Section 8) process whereby drugs which would otherwise be non-benefits of the plan can be considered on a case-by-case basis. The Special Program provides certain drugs at no cost to patients meeting certain clinical criteria, and is approved by a designated centre/physician for the drug. Conditions covered may include cystic fibrosis, thalassaemia, HIV, end stage renal disease, growth hormone failure, schizophrenia, Gaucher s Disease, and some transplant patients. Cancer Care Ontario provides some chemotherapeutic drugs to patients meeting eligibility criteria. OHIP list of eligible tests. Standard ward no charge. Daily room charge for Semi-private is $ to $ and $ to $ for private. $45.00 patient co-pay. One exam every 12 months for ages 19 and under and 65 and over. Those receiving social assistance or have an approved medical condition are also eligible for one exam every 12 months. Surgical procedures in hospital only. $500 per aid every 3 years. In OHIP approved clinics and LTC facilities for ages 19 and under and 65 and over up to $12.20 per visit and a maximum of 100 visits per year. All others up to $12.20 per visit to a maximum of 50 visits per year if required due to hospitalization overnight. When performed in an approved facility: $135 maximum (plus 30 for xray) per benefit year (July 1); $16.40 initial, $11.45 sub. Osteopathy:$155 max per benefit year (April 1); $12 initial, $9.50 sub, $25 for xray. Note: very few OHIP approved practitioners. Some asst' through ADP for a variety of devices. In-patient services are covered up to $400 per day and out-patient up to $50 per day, for emergencies only. required. This is intended as a general overview. For detailed information, contact the appropriate provincial Ministry of Health. GSC is not responsible for the accuracy of this information. It is to be used as a guideline only. 1 of 13

3 British Columbia Deductibles and family maximums are income based.once a family has reached their deductible level, seniors receive 75% reimbursement, while non-seniors receive 70% reimbursement for eligible costs. When the family maximum is reached, 100% of eligible costs are covered.drug formulary features include a reference drug program (for selected drug categories), and a Special Authorization Policy under which certain drugs are eligible only under specific clinical criteria.medications used to treat cancer are provided through the British Columbia Cancer Agency. With Rx and performed in an approved facility. Standard ward no charge. Daily room charge for Semi-private is $25.00 to $78.00 and $40.00 to $80.00 for private. Patient copay of $54 for all transports up to 40km and $.50 per km thereafter to a maximum of $274. Exams for ages 18 and under and 65+ Surgical procedures in hospital. Those receiving social asst' qualify for a paramedical combined max of 10 visits per year up to $23 per visit. Those receiving social asst' qualify for a paramedical combined max of 10 visits per year up to $23 per visit. Those receiving social asst' qualify for a paramedical combined max of 10 visits per year up to $23 per visit. Surgical podiatry services are covered for all. Those receiving social asst' qualify for a paramedical combined max of 10 visits per year up to $23 per visit (includes naturopathy and massage). Osteopathy as a physician visit. Some asst' through Pharmacare for ostomy supplies and prosthetic devices for ages 19 and under. In-patient services are covered up to $75 per day. Physician services and lab tests, inpatient and outpatient, up to the equivalent of the provincial rate. 2 of 13

4 Alberta Coverage is provided to seniors over the age of 65. Seniors must pay a 30% copayment to a maximum of $25 per prescription. There is a $25,000 maximum annual benefit.the drug plan includes a Special Authorization Policy under which certain drugs are eligible only under specific clinical criteria.the Widows Pension Program provides up to $818 per month in benefits to low income widows and widowers aged 55 to 64.The Alberta Cancer Board (ACB) provides some cancer drugs at no charge. used for the management of cancer pain, and those used for the management of chemotherapy side effects or infections are not provided by the ACB.The Province Wide Services Plan provides some transplant drugs, drugs for the management of HIV, as well as select other drugs for the management of diseases with very high-cost treatments. In-patient only. Standard ward no charge. Daily room charge for Semi-private is $24.00 and $40.00 for private. Hospital to hospital transfer only. Some asst' for seniors. One exam per year for ages 18 and under and 65+. Coverage for diagnosis of eye disease for all ages. Some surgical procedures when performed by dental surgeon. Various coverages based on medical criteria determined by each individual regional health authority (RHA). Beginning July 1, $13.23 per visit and $21.90 per x-ray to a max of $200 per benefit year. Note: private plan cannot pay until provincial plan is exhausted. Beginning July 1, $250 maximum per benefit year. Note: private plan cannot pay until provincial plan is exhausted. Osteopathy as a physician visit. Limited coverage for those who qualify under the Aids to Daily Living Program. Patient pays $25% of cost of benefits up to a max of $500 per family per benefit year. In-patient services are covered up to $100 per day, out-patient up to $50 per day and physician services up to the equivalent of the provincial rate. 3 of 13

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6 Manitoba The Pharmacare program is available to any Manitoban, regardless of age with high drug costs relative to their income. To qualify, residents must not have their drugs covered though any other federal, provincial, or private drug programs. The deductible is determined according to income, after which Manitoba residents are reimbursed at 100%. The drug plan includes a Exception Drug Status (EDS) program under which certain drugs are eligible only under specific clinical criteria.certain injectable cancer drugs are provided by CancerCare Manitoba. With Rx and performed in an approved facility. Standard ward no charge. Daily room charge for Semi-private is $40.00 and $65.00 to $80.00 for private. Some surgical procedures when performed by dental surgeon in hospital. 80% coverage for ages 18 and under, every 4 years. $75 deductible applies. When prescribed by a physician and performed in a hospital. $9.00 per visit for adjustments only, to a max of 12 visits per year. Some asst' through provincial plan for prosthetic devices. In-patient services are covered from $280 up to $570 per day and out-patient up to $100 per day. 5 of 13

7 Quebec Seniors over the age of 65 may obtain RAMQ coverage while maintaining their private or group plan as supplemental insurance. If they choose to maintain their group coverage and not to register for RAMQ, they must inform RAMQ of this decision. Premiums are income based, ranging from $0 to $494 per adult per year.a deductible of $8.33 per month applies to those receiving at least 94% of the maximum Guaranteed Income Supplement (GIS). A deductible of $10.25 applies to those receiving less than 94% of the maximum GIS.A copayment of 71.5% of 25% also applies, depending on the level of GIS received.the maximum monthly contribution may be $16.66, $46.67, or $71.42 per moth, depending on the level of GIS received. The maximum monthly contribution is the maximum amount a person is required to pay when purchasing insured drugs, and consists of the deductible and copayment. Non-seniors without private drug coverage are also eligible for RAMQ, subject to an income-based premium of $0 to $494 annually, and a $10.25 deductible per month. Reimbursement is 71.5% once the monthly deductible is satisfied. The maximum monthly contribution is $71.42 per month. RAMQ also includes limited used drugs or exceptional medications which are covered only when used for specific therapeutic indications. Quebec is also the only province which covers smoking cessation products on the provincial formulary. In-patient only. Standard ward no charge. Daily room charge for Semi-private is $50.45 to $71.15 and $81.51 to $ for private. For ages 65+ only. One exam every 12 months for ages 17 and under and 65+. Coverage for routine services for ages 10 and under. Surgical procedures when performed in hospital for all others. Coverage for purchase, modification, repair and replacement for those who meet criteria. Full coverage when provided by provincial association. When prescribed by a physician and performed in an approved facility on an outpatient basis only. Prosthetics, braces and mobility aids for permanently disabled residents. In-patient services are covered up to $100 per day and out-patient up to $50 per day. $220 for dialysis treatment. 6 of 13

8 New Brunswick Provincial coverage is available to seniors over the age of 65 receiving the Guaranteed Income Supplement. Seniors may also qualify based on annual income. There is no deductible. GIS recipients are responsible for a $9.05 copayment (to an annual maximum of $250). Non-GIS recipients are responsible for a $15.00 copayment.a Special Authorization process exists for drugs not otherwise covered by the New Brunswick Drug Program.A number of plans are available for certain cystic fibrosis, multiple sclerosis, organ transplant, HIV and Alzheimer s patients. Deductibles and copayments vary under these specialized programs. There is no specific cancer program in New Brunswick. In-patient only. Standard ward no charge. Daily room charge for Semi-private is $65.00 and $75.00 for private. Medically necessary hospital to hospital transfers only. Surgical procedures in hospital Some coverage if provided by provincial association. When prescribed by a physician and performed in a hospital. In-patient services are covered up to $100 per day and out-patient up to $50 per day. 7 of 13

9 Nova Scotia Seniors who have private drug coverage are eligible for Pharmacare only if their drug costs under their existing plan exceed the maximum cost they would have paid under Pharmacare.The premium for seniors not receiving the GIS is $390 annually ($32.50 per month). There is a copayment of 33%, to a maximum of $30.00 per prescription, and $350 per year.the plan includes an Exception Status program which covers certain products under specific clinical criteria, as well as a Special Authorization process for drugs not otherwise covered.the Drug Assistance for Cancer Patients Program provides benefits only to Nova Scotia residents with a gross family income of $15,720 or less, and who do not have coverage from other sources. Funding for multiple sclerosis drugs is available if no other drug coverage exists. In-patient only. Standard ward no charge. Daily room charge for Semi-private is $40.00 to $85.00 and $60.00 to $ for private. One exam every 24 months for ages 9 and under and 65+ Surgical procedures in hospital Some coverage if provided by provincial association. When performed in a hospital. Prosthetic equipment, artificial limbs once every 4 years, mastectomy prostheses up to $150 every 2 years. In-patient services are covered up to the equivalent of the provincial rate. 8 of 13

10 Prince Edward Island Coverage is available to Seniors over the age of 65, with a copayment of $10 of the cost of the drug plus the pharmacy s dispensing fee.a Family Health Benefit Program is available to low income families only.the plan includes an Exception Status program which covers certain products under specific clinical criteria.limited assistance is available for registered patients (of any age) with a variety of conditions including diabetes, multiple sclerosis, HIV, cystic fibrosis, etc. In-patient only. Standard ward no charge. Daily room charge for Semi-private is $80.00 and $ for private. $ patient co-pay. Coverage for routine services for ages 3 to 16. Partial coverage through the Program. When prescribed by a physician and performed in a hospital. Some coverage for prosthetics and supplies through various provincial programs. In-patient services are covered up to $887 per day and out-patient up to $153 per day. 9 of 13

11 Newfoundland & Labrador Seniors receiving the Guaranteed Income supplement are eligible for the Senior Citizens Drug Subsidy Program. The program covers a defined ingredient cost for the benefit, with the remaining amount (including dispensing fee) paid by the beneficiary. The amount charged by the pharmacy to the beneficiary is not regulated.the Income Support Program provides coverage those residents with high drug costs. Provides 100% coverage of the ingredient cost, up to a 10% markup where ingredient cost exceeds $30.00, and a maximum dispensing fee of $6.50. With Rx and performed in an approved facility. Standard ward no charge. Daily room charge for Semi-private is $85.00 and $ for private. Some assistance through provincially sponsored programs when prescribed by a physician. Coverage for routine services for ages 12 and under. Services are subject to copay and limited to exams every 6 months and cleanings every 12. Surgical procedures when performed in hospital for all others. When prescribed by a physician and performed in a hospital. In-patient services are covered up to $350 per day and out-patient up to $62 per day. 10 of 13

12 Yukon Yukon Pharmacare provides 100% coverage for seniors, and their spouse if that person is age 60 to 64. Non-seniors with certain chronic diseases also receive 100% coverage through the Chronic Disease Program.As of January 1998, the Child Drug and Optical Program will provide 100% coverage to age 19 (application required).a $250 deductible applies per year, and for a family this amount is doubled. Yukon Pharmacare is payer of last resort.the plan includes an Exception Drug Status Program covers certain products under specific clinical criteria. When performed in hospital. Standard Ward coverage. 65+ receive 100% coverage for one eye exam and prescription lenses each year. Children in grade K-8 receive coverage if performed in hospital. 65+ receive up to $1, every 2 years for services and dentures. Those 15+ under, who are not covered by parents' plan receive 100% coverage. 65+ receive 1 hearing aid every 4 years. When prescribed by a physician and performed in a hospital. Partial coverage for ostomy, durable medical equipment, supplies, oxygen, prosthetics, trusses, crutches and braces. Individuals suffering from chronic diseases receive 100% after satisfying $ deduction or $ fully deductible. Physician and hospital charges at provincial rate. 11 of 13

13 NWT Seniors receive 100% coverage.pharmacare is payer of last resort.the plan includes an Exception Drug Status Program covers certain products under specific clinical criteria. The plan includes a Special Authorization Process which covers certain products under specific clinical criteria. When performed in hospital. Standard Ward coverage. Coverage for air and land. Some coverage for those over 65. Some surgical procedures when performed by dental surgeon in hospital. 65+ receive up to $500 every 3 years. Limited re-imbursement. When prescribed by a physician and performed in a hospital. Speech and psychology services when performed in a hospital. Those without private coverage receive 100% re-imbursement for oxygen and prosthetics. Those with private coverage have 80% co-pay. Physician and hospital charges at provincial rate. 12 of 13

14 Nunavut Seniors receive 100% coverage. Pharmacare is payer of last resort.the plan includes an Exception Drug Status Program covers certain products under specific clinical criteria. The plan includes a Special Authorization Process which covers certain products under specific clinical criteria. When performed in hospital. Standard Ward coverage. Coverage for inter-facility and transfer only. Some coverage for those over 65. Some surgical procedures when performed by dental surgeon in hospital. 65+ receive up to $500 every 3 years. Limited re-imbursement. Those with no assistance coverage receive 100% coverage for home care service. When prescribed by a physician and performed in a hospital. Those without private coverage receive 100% re-imbursement for oxygen and prosthetics. Those with private coverage have 80% co-pay. Physician and hospital charges at provincial rate. 13 of 13