Preferred Pharmacy Network

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Exclusions


No benefit is payable for charges in respect of:
  • Services for which benefits are payable under any workers’ compensation act, any similar statute or by any government agency.
  • Services or supplies rendered or prescribed by a person who is ordinarily resident in the patient’s home or is related to the patient by blood or marriage.
  • Operations, treatments or supplies considered by Sun Life to be for cosmetic purposes, or for conditions not detrimental to health, except those required as a result of accidental injury or expressly provided for.
  • Any services of a practitioner that, in the opinion of Sun Life, are not within the practitioner’s area of expertise and do not require the skills and qualifications of such a practitioner.
  • Services or supplies normally rendered without charge.
  • Services rendered in connection with medical examinations for insurance, school, camp, association, employment, passport or similar purposes.
  • Services provided by a physician licensed and practicing in Canada where eligible to be covered under a provincial health plan, unless such services are specifically included.
  • Services or supplies payable or available (regardless of any waiting list) under any government sponsored plan or program unless explicitly listed as covered under the benefit.
  • Services or supplies that are not approved by Health Canada or another government regulatory body for the general public.
  • Services or supplies that are not generally recognized by the Canadian medical standards.
  • Services or supplies that do not qualify as medical expenses under that Income Tax Act (Canada).
  • The portion of charges that is the legal liability of any other party.
  • The portion of charges for services rendered or products provided in a hospital outside Canada that would normally be payable under a provincial health or hospital plan if the services had been rendered or products provided in a hospital in Canada, when covered by a provincial health plan.
  • Co-payment charges or similar charges for hospital care that are in excess of charges payable by a provincial or territorial government health or hospital plan and that are not charges made for utilization of semi-private accommodation.
  • Experimental products or treatments for which substantial evidence - provided through objective clinical testing of the product’s or treatment’s safety and effectiveness for the purpose and under the conditions of the use recommended - does not exist to the satisfaction of Sun Life.
  • Drugs that, in Sun Life’s opinion, are experimental.
  • Publicly advertised items or products that, in Sun Life’s opinion, are household remedies.
  • Vitamins (except injectables), minerals and protein supplements, unless specifically included.
  • Therapeutic nutrients, unless specifically included.
  • Diets and dietary supplements.
  • Infant foods and sugar or salt substitutes.
  • Lozenges, mouthwashes, non-medicated shampoos, contact lens care products and skin cleanser, protectives, or emollients.
  • Brand-name drugs, unless Sun Life has approved the exception request, or no generic equivalent drugs are available on the market.
  • Drugs that are used for cosmetic purposes.
  • Weight-loss drugs (includes injectable vitamins and dietary supplements prescribed by a physician in conjunction with a weight loss drug program) unless the covered person is deemed obese as defined by the World Health Organization (WHO).
  • Drugs that are used for a condition or conditions not recommended by the manufacturer.
  • Prescribed drugs that can be purchased over the counter.
  • Items purchased primarily for athletic use.
  • The regular treatment of an injury or disease that existed prior to your dependent’s departure, or your departure, from your province of residence.
  • Benefits which are legally prohibited by the government from coverage.
  • Surgical supplies and diagnostic aids.
  • Services that are not immediately required or which could reasonably be delayed until the person returns to the province where the person lives, unless their medical condition reasonably prevents the person from returning to that province prior to receiving the medical service.
  • Services relating to an illness or injury which caused the Emergency, after such Emergency ends.
  • Continuing services arising directly or indirectly out of the original Emergency or any recurrence of it, after the date that the Plan Administrator or Allianz Global Assistance, based on available medical evidence, determines that the person can be returned to the province where the person lives, and the person refuses to return.
  • Services which are required for the same illness or injury for which the person received Emergency Services, including any complications arising out of that illness or injury, if the person had unreasonably refused or neglected to receive the recommended medical services.
  • Where the trip was taken to obtain medical services for an illness or injury, services related to that illness or injury, including any complications or an emergency arising directly or indirectly out of that illness or injury.
  • Any portion of the charges for services or supplies over the customary and reasonable charges, in the locality where they are provided.
  • The portion of charges which are payable under a provincial health insurance plan or a provincially sponsored program.
  • Dental expenses, other than those indicated as Eligible Expenses.
  • Expenses for repairs or replacement of purchased durable equipment.
Published on February 01, 2016