What’s Covered?

Why do I need Health and Dental Insurance?

For prescription drugs! When many customers think of health insurance, they often pay close attention to dental care. And yes, while going to the dentist every 9 months is important, paying out of pocket for a checkup probably won’t bankrupt you like certain drugs can.

Having a good drug plan is important. If you don’t have an employee benefits plan through your work, having individual health insurance can save you thousands of dollars in unexpected drug costs.

Take Remicade for example: Remicade is a biologic drug that is very effective in treating rheumatoid arthritis. It can mean the difference between comfort and severe pain, and it cost about $30,000/year.

A recent article in the globe and mail tells a story of a teenager who needed an expensive biologic drug to manage severe pain, and his struggle to pay for treatment without drug coverage. This is a power story, but it puts


What’s Covered?

Individual Health and Dental plans cover many expenses not covered by your provincial health care plan.

Individual health plans typically include coverage for:

  • Prescription Drugs
  • Professional Services such as masseurs, naturopaths, chiropractors, psychologists, optometrists, acupuncturists etc.
  • Major Medical Supplies including braces, crutches, wheelchairs and Orthopaedic Shoes
  • Some form of hospital coverage in excess of that provided by provincial health care
  • Eye glasses
  • Emergency medical travel
  • Miscellaneous

Most insurers group their coverages into plans which they then characterize as Basic, Middle of the Road and Comprehensive.

The Principal differences between the 3 types of health plans revolve around Prescription Drugs as that by far and away is the most significant expense the Insurer’s have to pay.

As for the other Health expenses, the variations tend to revolve around what each of them considers “optional coverage” such as hospital or travel health insurance.

The monthly premium you’ll pay will be reflective of the type of plan you choose and the coverages that are offered under each plan. So.. as the old knight said in one of the Indiana Jones movies …..“Choose wisely” or call us.

Typical Dental Coverage will follow a similar approach to health. But what is important to note is that Dental coverage is usually only available in conjunction with a Health plan.

There are usually 3 levels of coverage, Preventive or Basic, Major and Orthodontic.

Basic Coverage will include items such as

  • Examinations and diagnosis
  • Fillings
  • X rays and lab exams
  • Extractions…. what are considered “minor”

Generally, the items that fall into the Basic category are what you would normally be treated for if you currently visit the Dentist every 9 months.

Major Coverage usually includes expenses such as

  • Endodontics and Periodontics
  • Oral Surgery
  • Crowns, Inlays and Onlays
  • Major Extractions and Dentures etc.

These types of expenses normally happen when your Dentist spots a “major problem” then asks you to return soon for treatment.

Orthodontic Coverage

This type of treatment used to be just for children but today its also being done on adults

As previously mentioned Dental coverage is usually only available in conjunction with a Health plan. The extent of coverage provided tends to follow the same type of format as Health insurance. The coverage provided will be limited by coinsurance or re imbursement percentages and maximum payouts per type of plan.

Internally most Insurance companies don’t really consider “dental insurance” as true insurance seeing as their reimbursement levels and maximum payouts are quite limited.

They look at this coverage as "pay as you go" and price it accordingly. If you wish to be "insured" for this type of coverage its available but in most instances, we don't recommend it.

What’s not covered?

Generally, prescriptions and treatments that are not medically necessary, are not covered.

The following are not covered:

Elective Cosmetic Surgery

Laser eye surgery



I am already taking medication, and I want those covered?

No problem, there are plans that cover existing drugs, and they are known as “guaranteed acceptance plans”. You can get a quote here, but the catch is that they have drugs maximums anywhere between $1,000 and $2,000.

There is plenty of other coverage included in guaranteed acceptance plans… but due to the low drug maximum, you should carefully weigh the pros and cons of covering your existing drugs.

For someone who is not on any drugs, or even for someone who is taking some inexpensive prescriptions… we highly recommend taking a standard plan which provides up to $100,000 of drug coverage per year.

What is the trillium plan?

Trillium is a government funded health plan, designed for individuals who spend more than 4% of their household income on drug costs.

To find out if your prescriptions will be covered you can search the drug formulary here.

To qualify, you must:

1. Have a valid ohip card,
2. Spend more than 4% of your household income on prescription drugs,
3. Be under the age of 65
4. Not be enrolled in Ontario works

What if I’m over 65?

In Ontario, you qualify for Ontario Drug Benefit when you turn 65. Most drugs are covered but not all, you can search here.

You would think that many policyholders would cancel their plans, but that’s not necessarily the case. There is plenty of other coverage included on the plan that makes it worthwhile to hold on to.

Should I keep my plan after 65?

Yes! You will still have coverage for..

Drugs not covered by ODB

Dental Coverage



Speech Therapist

Travel Health Insurance

Vision Care




Semi Private Hospital





Life Insurance quote Health & Dental Quote Group Benefits quote