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OPIP - Health and Health Plus Plan Details

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Health and Health Plus - Plan Details

Health and Health Plus coverage provides health-related services not covered by OHIP– including eligible drugs, hospitalization, paramedical services, assistive devices and more– for you and your family. Enjoy the added convenience of a pay-direct drug card as well as $2 million emergency out-of-country travel coverage.

Health Plus is enhanced coverage as shown below, and includes vision benefits.​​

Co-insurance​ for health and dental insurance refers to the portion that is paid by the insurance company. For example, a 90% co-insurance means the insurer pays 90% and you pay 10%.

The plan year for Health and Health Plus is January 1st to December 31st.​​ You have 180 days after the end of the benefit year (December 31st) to submit your claim expenses that w​ere incurred during that benefit year. 

The table below is intended as a summary of the coverages available under the Health and Health Plus plans to help you compare the two options. Eligible expenses means expenses incurred for services and supplies that are medically necessary for the treatment of an Illness or Injury and do not exceed the reasonable and customary charges for the service or supply being claimed. Actual coverage descriptions are contained in the policy and all claims are subject to the terms, conditions, and limitations contained therein.

Health Health Plus
Plan Maximum (Lifetime Reimbursement) Lifetime limits on expenses per insured person for:
  • $2,000,000 emergency out-of-province/country travel medical
  • $1,000,000 prescription drugs. Thereafter with annual reinstatement of $25,000 per person for drugs, if the lifetime maximum is reached.
Co-insurance
  • For the first $1,000 you claim, your insurance will reimburse you 50% of your eligible claims. Once you claim more than $1,000 you are reimbursed at 90% up to the limits stated in the policy
  • For the first $1,000 claimed by all of your eligible dependents combined, your insurance will reimburse 50% of their eligible claims. Once they claim more than $1,000 combined, the coverage is 90% up to the limits stated in the policy
Applies to prescription drugs, in-province hospital and convalescent hospital expenses, ambulance, nursing, medical equipment and services, paramedical services and hearing aids.
  • Your insurance will reimburse you 90% of your eligible claims up to the limits and caps stated in the policy.
  • Claims for your dependents will be reimbursed at 90% up to the limits and caps stated in the policy.
Applies to prescription drugs, ambulance, nursing and paramedical services.
Accidental Dental
  • Expenses incurred within 3 years of accident
  • $10,000 for any one dental accident
Ambulance
  • Unlimited ground and air ambulance
Emergency Out-of-Province/ Country Travel Medical
  • 100% of the cost of emergency services while outside your home province
  • Coverage for pre-existing medical conditions with no exclusions
  • Lifetime maximum of $2,000,000 per insured person
  • Coverage for the first 90 days of travel if under age 70
  • Coverage for the first 30 days of travel if age 70 or over

Hearing Aids
  • $500 every 4 plan years
  • $1,000 every 4 plan years
Hospital
  • Room and board charges between standard ward and semi-private rate
  • Room and board charges between standard ward and semi-private rate plus up to $100 per day for private room accommodation
Convalescent Hospital
  • Room and board charges if admitted within 24 hours following a period as an in-patient in a hospital (180 day maximum)
Medical Equipment
  • Wheelchairs - $5,000 lifetime maximum, and expenses are limited to the use of a manual wheelchair except if the insured's medical condition warrants use of an electric wheelchair
  • Hospital beds - $5,000 lifetime maximum
  • Wheelchairs - $5,000 every 5 plan years, and expenses are limited to the use of a manual wheelchair except if the insured's medical condition warrants use of an electric wheelchair
  • Hospital beds - no lifetime maximum
  • $5,000 maximum per plan year for purchase of braces, crutches, canes, and walkers as a result of illness or injury
Paramedical Services $350 per plan year per practitioner, per insured person can include:
  • Physician's order not required:
    • Licensed Chiropractor
    • Osteopath
    • Acupuncturist
    • Podiatrist
    • Licensed Naturopath
    • Chiropodist
    • Speech Therapist
    • Kinesiologist
    • Licensed Psychologist or Psychotherapist
    • Registered Massage Therapist
    • Physiotherapist - $1,000 per plan year per insured person
$500 per plan year per practitioner, per insured person can include:
  • Physician's order not required:
    • Licensed Chiropractor
    • Osteopath
    • Acupuncturist
    • Podiatrist
    • Licensed Naturopath
    • Chiropodist
    • Speech Therapist
    • Kinesiologist
    • Audiologist
    • Occupational Therapist
    • Dietician
    • Licensed Psychologist or Psychotherapist
    • Registered Massage Therapist
    • Physiotherapist - $1,000 per plan year per insured person
Prescription Drugs
  • Generic drugs (or brand name drugs when no generic equivalent is available) listed in federal or provincial drug schedules that have a Drug Identification Number (DIN) and require a prescription
  • $1,000,000 lifetime maximum per insured, once lifetime maximum is reached, annual $25,000 maximum reinstated
  • Injectible drugs, vitamins and allergy serums
  • Vaccines, whether or not they require a prescription
  • Fertility drugs up to $2,400 lifetime maximum
  • Diabetic supplies
Dispensing Fee
Eligible expenses for the dispensing fee are limited to 50% of up to $10 for each prescription or refill. The reimbursement level is increased to 90% once the out-of-pocket maximum for prescription drug expenses has been reached.
Dispensing Fee
Eligible expenses for the dispensing fee are limited to 90% of up to $11 for each prescription or refill.
Private Duty Nursing
  • Licensed, certified or registered nurse or nursing assistant who is not a relative of the patient or a resident in the insured's home
  • Prescribed by a physician and rendered outside the hospital
  • $25,000 every 3 consecutive plan years, if age 65 or under
  • $5,000 per plan year if over age 65
Medical Services
  • Laboratory tests, ultrasounds and other medical imaging services, blood oxygen, colostomy and ileostomy supplies, artificial limbs and eyes, radiotherapy, diabetic supplies and cosmetic surgery necessary to repair disfigurement due to an accident sustained while insured, up to $5,000 per plan year (some restrictions apply)
  • Breast prosthesis, $500 maximum per 2 plan years, per insured person
  • Masectomy brassieres, 2 per plan year, per insured person
  • Surgical stockings, 2 pairs per plan year, per insured person
  • Amputation socks, 5 pairs per plan year, per insured person
  • Wigs following chemotherapy, $500 lifetime maximum, per insured person
  • Continuous glucose monitors
  • Insulin pumps
  • Colostomy supplies
  • Orthopaedic shoes and orthopaedic modifications, and orthotics, maximum $400 per insured person in 2 plan years
  • Requires a doctor's prescription
  • Orthopaedic shoes and orthopaedic modifications, and orthotics, plus custom made orthotic inserts for shoes or custom made orthopaedic shoes or modification to orthopaedic shoes up to a combined maximum of $300 per insured person per plan year
  • Requires a doctor's prescription
  • Contact lenses or intraocular lenses following cataract surgery limited to a lifetime maximum of one lens per eye
Vision Care
  • Not included
For any insured person in 2 plan years can include:
  • $50 maximum per insured person every 2 plan years for ophthalmologist or licensed optometrist services
  • $300 per insured person
    • Under age 18 in a twelve month period or
    • For any other covered person in any 24 month period can include:
      1. Contact lenses, eyeglasses or laser eye correction surgery
      2. Requires prescription by an ophthalmologist or licensed optometrist
      3. Laser eye correction surgery must be performed by an ophthalmologist
      4. Prescription sunglasses, magnifying glasses or safety glasses for the correction of vision
      5. For coverage following cataract surgery, refer to medical services above
Survivor Benefit
  • Upon the member's death, coverage continues for 3 months on the insured spouse and/or the insured dependent children. After 3 months for spousal coverage to continue, the spouse must apply within 30 days of termination of coverage and continue to pay the premium.
  • Upon the member's death, coverage continues for 12 months on the insured spouse and/or the insured dependent children. After 12 months for spousal coverage to continue, the spouse must apply within 30 days of termination of coverage and continue to pay the premium.

​Download​ the my Sun Life Mobile app

Please register online at mysunlife.ca first before you use the app.

mysunlife.png
With the app you can:
  • Submit and track medical, dental and vision claims and see the money in your account – usually within 48 hours. You can also view your drug claim history over the past 12 months.​
  • Use your smartphone as your drug card.
  • Download, access and use the my Sun Life mobile app all for free! However, your wireless carrier’s data charges may apply if you are not connected to a Wi-Fi network. 
  • Download it today for iPhone, Blackberry and Android devices


To learn more about the my Sun Life mobile app visit sunlife.ca/mobile.

If you don’t have the my Sun Life Mobile app you can still file a claim by completing an Extended Health Care Claim Form (for Health claims only).

For details on converting between Health and Health Plus, see your benefits booklet or contact one of our OMA Insurance S​ervice Representatives who will be happy to help you.​