Definitions
Co-Insurance: Co-insurance is the rate at which benefits are payable.
Child: A child is your unmarried son or daughter. This includes a step-child, a foster child, and/or a common-law child. A common-law child means a child of your common-law spouse and another person. This child must be dependent on you and your common-law spouse for support and maintenance.
- A child must be under age 22 and dependent on you for support and maintenance
- Coverage is continued while the child is under the age of 25 and attending an accredited college or university on a full-time basis. Upon request, you must provide confirmation that the child is a full-time student and remains dependent on you for support and maintenance
- Coverage is continued beyond the maximum ages indicated above for a child who is physically or mentally handicapped as long as the child became handicapped before reaching the applicable maximum age stated above, and you provide proof satisfactory to us that the child is not capable of self-support due to the handicap
Covered Person: You or any one of your dependents who is covered under the contract.
Dependent: A dependent is your spouse or child. Anyone who is in the armed forces full-time is not eligible to be a dependent.
Drug: A medication that has been approved for use by Health Canada and has a Drug Identification Number.
Emergency: An emergency means any sudden, unexpected illness or injury for which the insured person needs immediate treatment.
Family: A family is you and all dependants who are covered under the contract.
Life-Sustaining Drugs: Non-prescription drugs, which are necessary to sustain life.
Lower-Cost Alternative: If two or more drugs, supplies, or services result in therapeutically similar results, the lower-cost alternative will be considered.
Medically Necessary: Accepted and recognized by the Canadian medical profession and NexgenRx as effective, appropriate, and essential treatment of a phase of an illness or injury.
Over the Counter (OTC) Drug: Drugs that do not require a prescription.
Patient Assistance Program: A program that provides assistance to you or your dependents who are prescribed select drugs or supplies. Manufacturers and distributors may provide patient assistance programs that include financial support, along with education and training.
Prior Authorization: A claims management feature applied to a specific list of drugs, supplies, or services to determine eligibility based on predefined clinical criteria and a pharmacoeconomic or cost-effectiveness evaluation.
Spouse: A spouse is a person to whom you are legally married or with whom you have a common-law spouse relationship. A common-law spouse means a partner whom you have lived with for at least 24 months. The maximum number of spouses that can be covered at one time is 1.
General Terms
Confirming Your Coverage
When your coverage begins, you will receive an information package. Upon receipt, please read carefully.
Changes to Report
It is important that you report the following changes immediately to Local 493 Benefits Services:
- Changes in dependent coverage, including the birth of a child.
- Change of spouse.
- Separated spouses may be removed with the consent of the spouse or by court order. Divorced spouses are not eligible for coverage. Separated common-law spouses are not eligible for coverage and coverage will cease on the date cohabitation ends.
- Change of name.
- Change from single or family status.
- Change of banking information, if NexgenRx is depositing your claim expenses directly into your bank account. You may also update your banking information online.
Legal Action
No legal action may be taken until 60 days after proof of claim is given to NexgenRx Inc. or more than one year after the deadline for providing proof of claim.