As an OPSEU/SEFPO OPS member, the following is offered through your Supplementary Health & Hospital (SH&H) plan (Policy number 15900) as an insured benefit:

• Fertility drugs, for treatment of infertility are reimbursed as prescription drugs at 90% less $3 per prescription deductible. For those in the Unified bargaining unit, reimbursement will be based on the lowest cost eligible generic drug product price, even if no substitution is prescribed by a Prescriptions are subject to a dispensing fee capped at $11.99 and subject to a frequency cap of five (5) times per calendar year.
• Cost of infertility treatments, rendered as an out-patient in a licensed and provincially funded hospital, excluding physician’s fees, special nurse’s fees and administrative costs. The only clinic that currently meets this criterion is Mount Sinai Fertility. Please note that there are no private clinics that are eligible, services rendered at a private clinic will not be covered.
• Blood tests done in conjunction with infertility treatments rendered in a licensed hospital are covered, except for tests covered by OHIP.
• Claims for In-vitro Fertilization (IVF) treatments must include an itemized list of each procedure, the date each procedure was performed and the name of the hospital where treatments were rendered. Before beginning infertility treatments, check with the Insurance Carrier to confirm which procedures and expenses are covered by the SH&H plan by obtaining a pre-determination. To file a predetermination, sign in to the Manulife secure online services website and submit the estimate to them for review. Ensure you indicate clearly that you have not incurred any expense and this is a predetermination. The estimate must include an itemized list of each procedure and the hospital where the treatment will be rendered.
• The plan pays the costs for eligible expenses that are reasonable and customary (as determined by the insurer) for the treatment of infertility and the hospital charges incurred as an out-patient in a licensed and provincially funded hospital for necessary medical or surgical treatment, excluding physician’s fees, special nurse’s fees and administrative costs.
• A fertility clinic may offer counselling services related to mental health concerns such as anxiety, stress over difficulties conceiving, relationship stress, considerations when thinking about being a single parent, While these services are not eligible for reimbursement under the fertility benefits in policy 15900, they are available under the Psychological Services benefit. Coverage for psychological services differs between the bargaining units:
  • Corrections: Coverage is available for charges for the services of a Psychologist or Social Worker (MSW) up to forty dollars ($40) per half-hour to an annual maximum of one thousand and four hundred dollars ($1400).
    • The per half hour cap does not apply to Correctional Officers or Youth
• Unified: Coverage is available for charges for the services of a Psychologist or Social Worker (MSW) up to eighty dollars ($80) per half-hour to an annual maximum of one thousand and six hundred dollars ($1600).
• Benefits for fertility treatment are essentially the same for both the Unified and Corrections members of the OPS however, the Unified members do have access to a Health Care Spending Account (HSCA) in the amount of $300 annually for each eligible regular and seasonal employee in the OPSEU/SEFPO Unified Bargaining The HSCA must be utilized for eligible medical expenses as defined in the Income Tax Act (ITA). Unified members may be able to claim expenses related to fertility treatments utilizing the HCSA if they are deemed eligible under the ITA, and are not otherwise covered by the Ontario Fertility Program or your insured benefits policy 15900.

The Ontario Fertility Program and your insured benefits

As of December 1, 2015, the Ontario Ministry of Health and Long-Term care introduced government- funded fertility treatments and participating fertility clinics across the province through the Ontario Fertility Program (OFP). For more information regarding the OFP please visit: Get fertility treatments | ontario.ca

 As a result of the introduction of the OFP, prior to allowing IVF expenses under 15900, the insurer requires that a member has gone through the government program first. This means that expenses under 15900 will not be considered until the second treatment.

Expenses not covered under the government program, could be considered under 15900 for the first treatment with specific criteria:

• IVF/IUI expenses are eligible for consideration when rendered as part of an out-patient program at a licensed hospital.
• There is no provision to cover IVF/IUI expenses rendered in a private clinic UNLESS the clinic is affiliated with a hospital to the extent that the clinic is funded by/through the hospital’s global budget. In this instance, the clinic would be considered an extension of the Presently the only approved fertility clinic is Mount Sinai Fertility.

What is covered under 15900

• Sperm wash
• Semen analysis
• Sperm preparation
• Preparation of donor sperm
• Embryo freezing
• Egg retrieval
• ICSI (Intracytoplasmic Sperm Injection) including ICSI with MESA (Microsurgical epididymal sperm aspiration)/TESA (testicular sperm aspiration), PESA (percutaneous epididymal sperm aspiration), MicroTESE sperm
• Blood work/ lab tests
• Assisted hatching
• IUI (intra-uterine insemination)
• Conversion to IVF from IUI
• Embryo transfer (fresh or frozen)

What is not covered under 15900

 Expenses for investigation and diagnoses of infertility are not

• Administration fee (including use of facility, clerical mailing, )
• Nursing fees (visits, phone calls, fees to administer injections, )
• Monitoring of lab results
• Block fees
• Freezing of sperm
• MESA/TESA, PESA and MicroTESE surgical and facility fees
• Sperm banking
• Egg/embryo storage fees
• Purchase of donor sperm
• Purchase of donor eggs
• Sperm storage fees
• Physician fees
• Genetic testing – diagnosis/screening (PGD/PGS)
• Thawing of blasts for biopsy purposes
• Embryo biopsy (if freezing is included in the expenses, freezing cost must be indicated separately)
• Counselling*

*Counselling services are not covered under fertility benefits in policy 15900 however, they are covered under Psychological Services.

N.B. before beginning infertility treatments, check with the insurance carrier to confirm which procedures are covered by the SH&H plan.

How can I appeal claims for denied insured benefits?

If you work in the Ontario Public Service (OPS) and are represented by OPSEU/SEFPO, you can appeal the denial through the Joint Insurance Benefits Review Committee (JIBRC).

The role of the Joint Insurance Benefits Review Committee

 The Joint Insurance Benefits Review Committee (JIBRC) is comprised of OPSEU/SEFPO representatives and Employer representative from the Treasury Board Secretariat (TBS). Claims submitted for appeal for denied insured benefits are reviewed by JIBRC. The JIBRC will review the claim, determine if there is a legitimacy to the claim and attempt to resolve the appeal. If the appeal cannot be resolved at the committee level, the appeal can be referred to the Claims Review Subcommittee (CRS). If the claim is referred to CRS, then it will be heard before a designated arbitrator and a final binding decision will be made.

Frequently Asked Questions

Why is the cost of infertility treatments only covered if the procedure is completed at a provincially funded hospital?

The reason IVF is covered at all is because coverage in your Supplementary Health & Hospital (SH&H) policy covers procedures that are not covered under OHIP done within a hospital. Since coverage for IVF has yet to be specifically negotiated, this is the reason why coverage is limited to procedures completed within a hospital or clinics who are globally funded by hospital budgets.

Are fertility drugs covered?

All drugs should be covered under the SH&H plan though are subject to some limitations. Article 39.2.1 outlines your coverage:

The Supplementary Health and Hospital Plan shall provide for the reimbursement of ninety percent (90%) of the cost of prescribed drugs and medicines that require a physician’s prescription. The Supplementary Health and Hospital Plan shall provide reimbursement for ninety percent (90%) of the generic equivalent where a generic equivalent exists. Where the brand name product is dispensed, the employee will pay the difference between the cost of the brand name product and ninety percent (90%) of the generic equivalent product cost that is reimbursed by the Supplementary Health and Hospital Plan. Notwithstanding the foregoing, if no generic product exists the Supplementary Health and Hospital Plan shall provide reimbursement for ninety percent (90%) of the cost of the brand name product. Reimbursement of prescription drugs will include a three-dollar ($3) deductible per prescription to be paid by the employee.

In addition to the coverage mentioned above, the following limitations exist for Unified members:

• With the implementation of a Prior Authorization program, during your last round of negotiations, you may need to complete Prior Authorizations for use of some medications to ensure you qualify for Decisions are based on criteria set out by Manulife’s pharmacists (e.g. unsuccessful use of prior, less expensive options; contraindication for less expensive options etc.)
• Reimbursement will be based on the lowest cost eligible generic drug product price, even if no substitution is prescribed by a physician. If a patient cannot tolerate the generic drug, or it is therapeutically ineffective, medical evidence can be submitted to support why the brand-drug is being prescribed.
• A Dispensing Fee Cap for prescription drugs of $11.99 per Any dispensing fee above the $11.99 threshold, will be paid for by the member. There is also an Annual Dispensing Fee Frequency Cap of five (5) times per calendar year in relation to eligible prescribed maintenance drugs that can be reasonably dispensed over a longer term.

Are tests for the treatment of infertility covered?

 Blood tests done in conjunction with infertility treatments rendered in a licensed hospital are covered, except for tests covered by OHIP. Expenses for investigation and diagnosis of infertility are not covered.

Is there a list of private clinics that are covered?

 IVF treatments rendered in a private clinic are only covered if a private clinic is affiliated with a hospital to the extent that the clinic is funded through the hospitals global budget. The only clinic currently approved is Mount Sinai Fertility.

How do we make changes to the coverage or have coverage extended to additional procedures, diagnostic testing, and facilities?

Any changes to benefits are gained through the bargaining process. What is important to you, will likely be important your colleagues. The first step to affecting any change is garnering support. You will want to talk to your colleagues early and often to build support over time and build capacity leading up to your next round of negotiations. Providing information, education and resources to your local leadership and your colleagues will be important to garner support for the change you want to

see within your Collective Agreement. Bargaining begins essentially as soon as a Collective Agreement is ratified, meaning, you need to provide information and education to your co-workers often and early. That way, when your next round of bargaining is imminent, the seeds have already been planted and you’ll ideally already have the support necessary to support the change you want to see.

Next it is important that you participate in the demand setting process and encourage your colleagues to do the same. Ensure you complete the demand set survey and attend your locals meeting for the demand set process. When you attend the meeting, speak to the changes you want to see in your collective agreement. YOU are OPSEU/SEFPO. If you want to see a change, you have to participate in the process, show solidarity and support your bargaining team through the bargaining process. No change will happen without YOUR support.

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