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Find out if you’re covered before paying ‘out-of-pocket’


Before you spend your money on medical equipment/services, expensive dental work or drugs that need to be pre-approved, we encourage you to get an estimate or pre-determination, check if your service provider has been delisted and review your reasonable and customary (R&C) limits.  
 
It’s important to find out if you are covered before paying out-of-pocket for claims.
 
By submitting an estimate or pre-determination and reviewing your R&C limits, you will know how much is covered under your benefits plan and how much you will be responsible for paying out of your own pocket. This will help you to minimize expenses and avoid disappointment if your claim is not eligible for full or partial reimbursement.

Here is a list of items we recommend you submit an estimate or pre-determination for:

  • Medical equipment and services that cost more than $300 (e.g. orthopaedic shoes, compression stockings, knee braces, orthotics, glasses, contact lenses, etc.).
  • Expensive dental work. Your dentist knows the information claim payers need. Most dentists can submit an estimate for you, or you can submit it yourself.

The process to submit an estimate or pre-determination is similar to submitting a claim and can be done online in My Claims.

  • Drugs that need pre-approval. Your health-care provider may prescribe medication that needs prior authorization. Drug prior authorization is an approval process to ensure that certain medications being prescribed are covered under your benefits plan. You can use the online tool, My drug plan, to look up a drug and find out whether it is covered under your benefits plan or if prior authorization is needed. You can also see the approximate out-of-pocket expense to purchase the drug, as well as any alternatives (such as a generic version of the drug). Read our four simple steps to help guide you through the drug prior authorization process for more information.
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IMPORTANT information about de-listed providers: Some service providers have been delisted by your claims payer, Manulife. This means that claims submitted for services provided by a delisted provider will not be covered under your plan.
 
To view a list of delisted providers, visit how can I view the list of delisted providers.

Want to know more about R&C limits and your benefits coverage? R&C limits refer to the maximum allowable amount that your insurer will reimburse on a particular service or item. This amount usually reflects the typical cost associated with this service or product .
 
Find out what your reasonable and customary limits are.
 
Questions? We’re here to help. You can contact OTIP Benefits Services at 1‑866‑783‑6847 or send us an online note.

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