Coordination of Benefits – If you have health or dental coverage under another plan, you can get up to 100% of your eligible expenses covered. Industry-wide procedures, determined by Canadian Life and Health Insurance Association (CLHIA) guidelines, establish which plan considers a claim first. Through coordination of benefits, you can submit the unpaid part of a claim to the second plan for payment. For example, if this plan pays 80% of an expense, the other plan may pay the remaining 20%.
Deductible – The eligible expenses we deduct from your claim before your plan pays a benefit.
Reasonable & Customary Charges – Those charges that are usually made in the absence of coverage for a specific type of care, service or supply, based on representative fees and prices in the geographic area in which the charges for the care, service or supply were incurred, as determined by the Insurer.
Drug Identification Number – The Drug Identification Number (DIN) is the number located on the label of prescription and over-the-counter drug products that have been evaluated by the Therapeutic Products Directorate (TPD) and approved for sale in Canada. A DIN lets the user know that the product has undergone and passed a review of its formulation, labeling and instructions for use. A drug product sold in Canada without a DIN is not in compliance with Canadian law.
Predetermination of Benefits
- A predetermination of benefits tells you if a dental procedure or service is covered by your plan and what your portion of the costs will be. Your dentist can provide you with the forms, which must then be completed and submitted to OTIP. You will receive a copy of OTIP’s assessment of the predetermination, outlining how much of the procedure is covered by your plan, to share with your dentist.
- Please be advised, we cannot provide a predetermination for dental lab fees. You should ask your dentist for a predetermination if the procedure is costly (i.e., over $500). Your dentist should submit x-rays for predeterminations of all major services. The x-rays will be promptly returned to your dentist once the review is complete.
Explanation of Benefits – You will receive an explanation of benefits (EOB) from OTIP for each claim you submit. An EOB is a statement of benefits paid or expenses reimbursed and will be attached to your claim cheque or posted online if you take advantage of our direct deposit service. You will need this statement if you are coordinating your benefits between two plans.
Copayment – The copayment is the contribution you are required to make towards certain expenses covered under the group plan.
Dispensing Fee – As part of their professional practice, pharmacists receive a dispensing fee for filling prescriptions. The dispensing fee compensates the pharmacist for providing professional services such as patient counselling, monitoring drug therapy, providing drug information to physicians and dispensing drug products. It also covers stocking of medication, maintaining patient medication records, general operating costs such as employees' salaries, rent, etc. The ministry also pays a mark-up to pharmacists, for most ODB eligible prescriptions, which is intended to cover these distribution and inventory carrying costs.
There are two kinds of dispensing fees in Ontario: the Ontario Drug Benefit (ODB) dispensing fee, and the "usual and customary" dispensing fee for non-ODB prescriptions.
Ontario Drug Benefit Program – As an Ontario resident, you are covered by the Ontario Drug Benefit (ODB) Program starting on the first day of the month following your 65th birthday. This means that many of your prescriptions may be covered by the government. All RTIP plans will pay a portion of the $100 ODB deductible charged to most Ontario residents. More information.
Trillium Drug Program – The Trillium Drug Program provides assistance for residents of Ontario who have high medical expenses. Trillium application kits are available at your local pharmacy or by calling 1-800-575-5386. The application form and guide are also available online on the Government of Ontario Web site (www.gov.on.ca) under Forms.
Assistive Devices Program – The Assistive Devices Program (ADP) provides consumer-centered support and funding to Ontario residents who have long-term physical disabilities and also provides access to personalized assistive devices appropriate for the individual’s basic needs. The ADP covers over 8,000 separate pieces of equipment and supplies in several categories and provides grants for ostomy supplies, breast prostheses and needles and syringes for insulin-dependent seniors. For more information, please call the Assistive Devices Program at 1-800-268-6021.