Frequently Asked Questions

Coverage
Opting Out
Death of a Beneficiary
Spouses
Dependants
Other

Please refer to the Benefits Summary of Coverage which can be found in the document library.

For Pensioners: Out-of-Province Emergency Treatment is covered (inside Canada only), but there is no out-of-country emergency medical coverage.

For Active employees: Emergency Medical Out-of-Province/Out-of-Country, Travel Assistance Coverage is available for the first six weeks after leaving the province of residence.

Further details can be found in the summary booklet within the document library.

Generally, if you were hired January 1, you will receive the Welcome Package by mid February. Your coverage, and your dependant’s coverage, will start January 1. The Welcome Package will contain the necessary forms to add dependants and elect Optional coverage(s). Coverage in any Optional plan is always future-dated. Therefore, it would become effective on the first of the month following the receipt of the forms.

Drug plans work off of a formulary, which is the list of drugs covered by our health benefit plan - Green Shield Canada (GSC). Managed formularies are often used by provincial drug plans to manage costs effectively. For example, the Ontario Drug Benefit (ODB) Program, the plan for seniors over 65, is a managed formulary.

The United Church uses a managed formulary (see the GSC video for more information), which means all drugs newly approved in the Canadian market are evaluated by a GSC committee of pharmacy experts before being added to the formulary for reimbursement. Drugs are assigned to one of three categories: “covered,” “not covered,” or “prior authorization required.”

  • Covered drugs are full benefits of the plan.
  • Not covered status are drugs that provide no additional therapeutic value over those already listed in the formulary or no cost advantage when compared to existing alternatives.
    • Plan member can pay the full drug cost or consult their prescribing physician about alternatives.
  • Prior authorization required is assigned to drugs considered a second-line therapy or are high-cost specialty drugs with potential for inappropriate prescribing and use.
    • Plan member must meet specific criteria to access benefits; first-line therapy must appear in claims history for auto-approval and/or the prescribing physician completes a special authorization form indicating therapeutic need.

This type of formulary “management” balances the need of plan members to have access to medically necessary drug therapies with plan sustainability.

You can check the Plan Member Online tool, offered by Green Shield Canada, to find out if your drug is covered, or will need prior authorization. It can be found under the “Your Health Benefits” heading, then select the “Drug” tile. You’ll be able to find out:

  • whether a drug is covered under your drug plan
  • if you will need to pay a copayment (and if so, how much)
  • if the drug needs a physician’s authorization (and if so, whether your doctor can print the authorization form directly)

Enter the name or DIN number of your drug, then select who the drug is for on your plan.

A few tips

  • Drug Name: you must enter at least the first three letters of the drug name. For example, if you enter “Tyl” for Tylenol, then all drug names that begin with “Tyl” will be displayed.
  • DIN: to search by DIN, the full DIN must be entered for the search tool to display the drug.
  • Select Participant: some drugs have use restrictions based on things like your age. This is why the tool will ask who the drug is for under your plan.

To access the tool, you will have to register for an account with Green Shield Canada (GSC) everywhere. If you haven’t registered, here is a video guide that can walk you through the registration process.

You can also call in to the call centre and check with an agent. 1-888-711-1119

Under the managed formulary, it’s possible for both the generic and brand name drugs to be listed. Assuming both the generic and the brand name drugs are on the formulary, the rules for generic substitution would apply, namely, if a brand-name drug is prescribed when there is a generic (or lower-cost) equivalent available, coverage will be based on the lower-cost drug unless your doctor specifies that the brand-name drug is required.

We encourage you to discuss generic alternatives with your doctor, as cost differences can be significant.

For a drug that is in the “prior authorization” category, the use of a recognized first-line drug is required before approval of a more complex second-line drug is given. Plan member must meet specific criteria to access benefits; first-line therapy must appear in claims history in order for the drug to be auto-approved. Otherwise, the prescribing physician must complete a special authorization form indicating therapeutic need.

Yes, they may. A pharmacist always has the authority to review and substitute.

At Green Shield, drugs are reviewed by a committee of pharmacy experts to establish the overall value of each drug and determine where it should be placed on our formularies. Their criteria, based on objective medical evidence, evaluates the drug’s clinical efficacy, safety, and the unmet need it fulfills to establish the value it offers to plan sponsors and plan members. The committee reviews drug submissions from manufacturers including clinical trials and other available evidence. The six pharmacists on the committee cover a range of experience and expertise:

  • Community pharmacy, including compounding
  • Hospital pharmacy
  • Specialty care, including oncology and transplant
  • Public payor
  • Pharma industry
  • Quebec market

Plus, there’s a nurse with clinical and health care navigation experience on the committee, and a committee member with a PhD in health policy.

If you are an active employee you cannot opt out of the core benefits, however, you may waive participation in the Health and Dental part of benefits if you have another privately sponsored plan. Please note, it does not save any premiums because core benefits are assessed as one benefit, fully paid by the employer.

When you apply for your pension you must decide whether to participate in the pensioner health and dental plan. You may choose one of three actions:

  1. Opt for coverage: This election isirrevocable. However, if you gain a compatible coverage elsewhere, you may waive participation in the United Church plan within 60 days of acquiring the other coverage. Upon losing it, you may rejoin the United Church plan within the 60 days of loss of alternative coverage.
  2. Decline coverage: This election isirrevocable.
  3. Waive coverage if you or your spouse have comparable coverage from another plan. In the future, if you lose that other coverage you may join the United Church pensioner health and dental plan within 60 days of losing the other coverage.

Upon retirement you have the option of not joining the retiree health plan. Once you have joined, you cannot opt out at a later date. Qualifying “Life events” provide an opportunity to change status (family/single).

For dependent children, the first payer is the insurance company of the parent whose birthday comes first in the year.

You will need to assign a new beneficiary if your beneficiary predeceased you. Please fill out the beneficiary form located in the document library and return to the Benefits Centre at benefits@united-church.ca

Contact the Pension Team at pension@united-church.ca and provide the death certificate. The Pension Team will send a package to start the death claim process. If the member has group life insurance, the Benefits team must also be notified at benefits@united-church.ca

It is advisable for members to always declare their spouse as a dependant to be eligible for Core dependant’s life insurance: a benefit payable to you in the event of your dependant’s death.

At the time of the member’s death, a surviving spouse (the spouse on record at the time the pension began) who is eligible for the United Church of Canada pension may elect to continue with the Pensioners Health and Dental plan, decline the coverage or waive it, if they are currently covered by another plan. If the member only had single coverage (rather than family coverage that included the spouse) the survivor does not have an option to join the plan at the time of member’s death.

  • Your legal spouse/partnerby virtue of religious or civil ceremony, or common law provision,
  • Your unmarried childrenunder 18 years of age, or under age 25 if still in school full-time (age 26 in Quebec for drugs coverage only)
  • Your unmarried children if they are unemployableby reason of mental or physical handicap (that commenced while covered as an eligible child). Proof of incapacity is required. Please contact the United Church Benefits Centre at benefits@united-church.cafor an application form.

It is crucial that you inform the Benefits Centre of any additional dependants that need to be added to your plan. Please fill out the “Enrol, Life Event and Dependant” form located in the document library and return to the Benefits Centre at benefits@united-church.ca

The disabled dependant form cannot be made available online at this time. Please contact the Benefits Centre at benefits@united-church.ca

The plan currently covers dependants to the age of 25 if they are full time students (in Quebec 26 for drug coverage only). When the dependant turns 18, the plan requires written confirmation that the dependant is a full-time student and asks for the name of the school.

Please complete the over-age dependant form found within the document library and return this to the Benefits Centre at benefits@united-church.ca.

Requests for additional coverage, for example eyeglasses, are reviewed annually. The process involves comparison with market experience with the benefit and anticipated cost of claims against the new benefit. Any new benefit cost has to be offset by an increase in premium or an equal value reduction in another benefit.

Benefits that are covered by the plan but not claimed against the plan do not add cost to the plan. The only costs to the plan are the actual reimbursements to members and administration. For example, 80% of fertility drug costs, to a lifetime limit of $3,500, are covered by the pensioner’s plan. This is a holdover from when we purchased an insurance product. Because there have been no claims on record against this benefit, it has not cost the plan anything.

If you leave work due to an illness or injury and are absent for more than two weeks you may qualify to apply for the Restorative Care Plan (RCP). The goal of the RCP is to support members while they recover and prepare to return to work safely. RCP lasts six months and you continue to be covered under the benefits plan. Your Employer will continue to pay you your salary and premiums will continue to be deducted as they were prior to RCP. No action is required from you in this scenario. If you are away from work for longer than six months, you may be eligible for a transition to the long-term disability (LTD) plan. You continue to be covered by the benefits plan if you go onto LTD, but you are not required to pay the premiums for the benefits coverage until you are no longer disabled or reach age 65, at which point the disability program ceases. To learn more about the disability programs, please click Health & Benefits.

Should you go on an unpaid protected leave in accordance with the legislation in your province of employment, such as maternity, parental or compassionate leave, the pension and health benefits can continue, provided you pay any contributions you would normally pay. The employer is obligated to pay at least the same share of contributions as if you were not on leave, however, this does not apply if you choose not to continue paying your share of premiums/contributions. To arrange for benefits coverage to continue please contact the Benefits Centre at benefits@united-church.ca. The team will provide you with monthly amounts owed and will set up direct billing (a Pre-Authorized Debit Agreement authorizes the United Church of Canada Benefits Centre to debit your financial institution account for a previously defined amount each month to maintain benefits coverage and/or contributions into the pension plan).

For information around any other types of leave, please contact the Benefits Centre at benefits@united-church.ca.

Our staff works with external consultants to review the plan benefits and industry standards annually. They also go to market with our plan every five years. Competitive bids are assessed against fees, service quality, Canadian-base, and other factors.

Green Shield Canada is the current administration service provider. It is hired to adjudicate (judge) claims and administer reimbursements. On a monthly basis, the United Church reimburses Green Shield for the amount actually paid out to plan members.

Generally, benefits first paid by the member can be claimed online with the claim usually adjudicated within 48 hours and electronic payment to the members bank account within another 48 hours. Drug claims are usually settled online by the pharmacy at the point of sale, with no further claim, payment or action required by the member.

Unfortunately, claims mailed to Green Shield are subject to the vagaries of Canada Post. However, when specific service complaints are brought to the attention of the benefits team, they are investigated and addressed with Green Shield.

Prescription renewal periods are defined by the prescribing physician and limited by provincial Colleges of Pharmacists to a maximum of 100 days and not determined by the plan terms or by Green Shield.

Members may request that their pharmacist reconcile the renewals to a single cycle or subscribe to the new all-Canadian ‘PocketPills’ on-line pharmacy option which was introduced to plan members in 2021 as a voluntary option. This service not only reconciles the renewal dates but it blister-packs and mails the next 100 days of medication automatically.

No, you will not. However, in order to maximize your reimbursement, you should advise all insurance carriers as there is a particular order that carriers are obligated to pay. The first payer is the employee’s own insurance. If the employee has more than one coverage, the first payer is the carrier of full-time employment, followed by the carrier of part-time employment or the pension plan insurer. If the first payer does not reimburse the full cost of a claim, the next insurer should receive a claim for the remaining amount, and so forth, until the entire expense is reimbursed. If the employee is also covered by a spousal insurance, the employee's own insurance is the first payer.

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