SOP on Uninsured Medical Expenses
and Out of Pocket Expenses (Plans ss. 4.06, 4.07)
Medical Expenses
1. In consultation with a gastroenterologist or
any of the other specialities of physician which
appears on Tran 2/Hemo 2 ("HCV Medical Specialist")
the Administrator shall compile a list of medications/treatments
which are recommended/prescribed for persons who
have HCV and for conditions due to infection with
HCV or treatment of HCV and which are generally
accepted by the medical community (the "HCV
Medication List"). This list shall be periodically
updated at the Administrator's discretion.
2. The Administrator may accept a completed Gen
3 accompanied by receipts as proof of medical expenses
incurred for any of the items on the HCV Medication
List, except where:
(a) the total claimed on any one application
exceeds $500 excluding the costs of HCV Compensable
Therapy;
(b) the level of medical expenses claimed is
inconsistent with the HCV Infected Person's overall
application or disease level (eg: a person who
is at Level 1 and has a negative PCR test claiming
for significant medical expenses); or
(c) for any other reason the Administrator suspects
the claim is not valid and wants the backup of
a physician confirming the medications were prescribed
or recommended as generally accepted treatment
or medication due to HCV.
3. Where reimbursement is claimed for items which
are not on the HCV Medication List, where one of
the exceptions described above applies, or where
there are items for which a claim is made but no
receipts are available, the Administrator shall:
(a) require the HCV Infected Person to supply
a form completed by a treating physician confirming
that he or she recommended the claimed items;
and
(b) consult a HCV medical specialist (if the
treating physician is not an HCV medical specialist)
to advise whether the items are generally accepted
by the medical community for the treatment of
HCV.
Out of Pocket Expenses
4. The Administrator may accept a completed Gen
3 accompanied by receipts (for those items which
should be the subject of a receipt) as proof of
out of pocket expenses due to HCV infection, except
where:
(a) the total claimed on any one application
exceeds $500;
(b) the level of expenses claimed is inconsistent
with the HCV Infected Persons overall application
or disease level (eg: a person who lives in a
major centre claiming travel costs to doctors
appointments or a person who is at Level 1 and
has a negative PCR test claiming for frequent
appointments with doctors); or
(c) for any other reason the Administrator suspects
the claim is not valid and wants the backup of
a physician confirming the expenses were incurred.
The maximum paid for expenses which are covered
by the Treasury Board of Canada Secretariat Travel
Directive shall be the amounts stipulated in the
Treasury Board of Canada Secretariat Travel Directive,
and
5. Where one of the exceptions described above
applies or where there are items claimed for which
the HCV Infected Person does not have receipts but
should have a receipt, the Administrator shall:
(a) require the HCV Infected Person to supply
a form completed by a treating physician confirming
that the HCV Infected Person had to incur the
expense in order to seek medical advice or treatment
for infection with HCV;
(b) in the event that item for which reimbursement
claimed is such that it is not amenable to confirmation
by the treating physician, seek such additional
evidence as the Administrator considers appropriate;
and
(c) consult a HCV medical specialist (if the
treating physician is not a medical specialist)
to advise whether the treatment or medication
to which the expenses relate are generally accepted
by the medical community for the treatment of
HCV.
6. With respect to compensation
for forms which must be completed by a treating
physician in order to obtain compensation, the Administrator
shall have regard to the BCMA position on reasonable
fees as stipulated in the letter from the BCMA dated
June 15, 2000.
Disclaimer
This Standard Operating Procedure is intended to
assist the reader with respect to the subject matter
and the procedures set forth in this Standard Operating
Procedure, however, in the event there is any difference
or ambiguity between this Standard Operating Procedure
and the 1986-1990 Hepatitis C Settlement Agreement
such difference or ambiguity will be governed
by and will be resolved by the terms of the 1986-1990
Hepatitis Settlement Agreement.
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