Health, Drug and Dental Coverage

The terms

Extended health care

EHC

The umbrella line covering everything medical that is not dental — drugs, paramedical practitioners, vision, medical equipment, hospital upgrades and out-of-country emergency care.

Usually the largest and most volatile line on a small plan, and where most of the design conversation happens.

Co-insurance

CO-PAY

The share of an eligible expense the plan reimburses — 80%, 90% or 100% — with the member paying the rest.

The most powerful cost lever and the most under-used. Moving from 100% to 90% on health typically returns mid-single digits, because member cost-sharing suppresses discretionary use. A plan at 100% has surrendered that lever entirely, and some small-group markets will load or decline it.

Deductible

An amount the member pays before the plan responds — annual or per-prescription, per person or per family.

A small per-prescription deductible is among the least painful savings on a rich plan. Members barely register a few dollars a script, and claim volume drops measurably.

Formulary

The list of drugs the plan covers. An open formulary covers essentially anything with a DIN requiring a prescription. Managed or national formularies cover a curated list, generally excluding drugs with cheaper therapeutic equivalents.

Open to managed is a real saving and a real reduction in coverage. Any member currently on an excluded drug feels it immediately — never do it without an exception process in place.

Drug identification number

DIN

The Health Canada number identifying a specific drug product. Adjudication runs on the DIN, not the drug’s name.

When a member says their drug is not covered, the answer is nearly always DIN-level — a different manufacturer, strength or format of the same molecule. Ask for the DIN before escalating anything.

Mandatory generic substitution

The plan reimburses at the price of the lowest-cost interchangeable generic regardless of what was dispensed, unless a prescriber documents a medical reason.

Standard on modern plans and rarely contentious. If a small plan lacks it, that is free money sitting on the table.

Prior authorisation and step therapy

High-cost drugs require clinical approval before reimbursement. Step therapy requires a cheaper first-line therapy to be tried and shown ineffective first.

These are what make an open formulary affordable on a small plan. An insurer quoting an open formulary without them will price it accordingly.

Pay-direct drug card

Real-time adjudication at the pharmacy counter, as opposed to pay-and-submit reimbursement.

Members judge the entire plan by whether the card works at the till. The most visible service feature you can change, and worth weighting heavily when choosing between insurers.

Dispensing fee cap

A ceiling on the pharmacy fee the plan reimburses per prescription, independent of the drug cost.

Invisible to most members, meaningful in aggregate, and it nudges people toward lower-fee pharmacies and ninety-day fills. One of the cleanest savings available.

Paramedical maximum

The annual limit for practitioner services — physiotherapy, massage, psychology, chiropractic — set per practitioner type or as a combined pool.

A per-practitioner limit is far richer than a combined one at the same headline number, since it can be claimed several times over. Check the structure before calling two plans equivalent.

Dental fee guide

The provincial dental association’s suggested fee schedule. Plans reimburse at the current year’s guide or a lagged prior year.

A lagged guide is a quiet saving and a quiet member irritation — they get balance-billed the difference. Always identify which guide a quote uses.

Basic, major and orthodontic

The three dental tiers. Basic is diagnostic, preventive and fillings; major is crowns, bridges and dentures; orthodontic is separate, usually with its own lifetime maximum.

Watch for a combined basic-and-major maximum, which is much less generous than it sounds — one crown can consume the year’s allowance for both.

Recall frequency

How often the plan pays for a dental cleaning and examination — every six, nine or twelve months.

Stretching recall from six to nine months is one of the least-noticed dental savings available, and it does not reduce anyone’s maximum.

Coordination of benefits

COB

Where two plans cover the same person, the rules deciding which pays first. A member’s own plan is primary for themselves; for children, the parent whose birthday falls earlier in the calendar year is primary.

A group with many dual-covered spouses will show a better loss ratio than its plan design suggests — genuinely useful when explaining unusually good experience.

Out-of-country emergency

Emergency medical care while travelling, subject to a trip-duration limit and often to stability requirements for pre-existing conditions.

Trip-duration limits catch people out constantly — snowbirds and long-stay travellers exceed them without realising. Worth flagging to staff once a year.