O. Reg. 276/18: PRESCRIBED POLICY STATEMENTS

Item

Column A
Medical Conditions that Require a Special Diet

Column B
Whether Medical Condition may Cause Weight Loss

Column C
Monthly Amount for Special Diet Unless Otherwise Specified

1.

Amyotrophic Lateral Sclerosis

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

2.

Anorexia Nervosa

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

3

Congenital heart defect — Have had Ross procedure or arterial switch procedure or have coexisting coarctation of aorta

No

$86, subject to subsection 2 (4)

4.

Celiac Disease

No

$97, subject to subsection 2 (7)

5.

Chronic Hepatitis C (BMI < 25)

No

$88, subject to subsection 2 (4.1)

6.

Chronic Hepatitis C (BMI < 25) with interferon treatment

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2) and subject to subsection 2 (4.2)

7.

Chronic wounds or burns requiring protein — Stages 1 and 2 chronic wounds
Burns 1 - 10% body surface area

No

$88, subject to subsection 2 (5)

8.

Chronic wounds or burns requiring protein — Stages 3 and 4 chronic wounds
Burns > 10% body surface area

No

$191, subject to subsection 2 (5)

9.

Cirrhosis Stages 3 and 4

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

10.

Congestive Heart Failure

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

11.

Crohn’s Disease

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

12.

Cystic Fibrosis

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

13.

Diabetes

No

$81, subject to subsection 2 (4)

14.

Dysphagia, requiring thickened fluids

No

$125

15.

Extreme Obesity: Class III BMI > 40

No

$51, subject to subsection 2 (4)

16.

Food Allergy — Milk/Dairy — 1 to 8 years of age

No

$32

17.

Food Allergy — Milk/Dairy — 9 to 18 years of age

No

$63

18.

Food Allergy — Milk/Dairy — 19 to 50 years of age

No

$32

19.

Food Allergy — Milk/Dairy — 51 years of age or older

No

$47

20.

Food Allergy — Lactose Intolerance — 1 to 8 years of age

No

$30, subject to subsection 2 (6)

21.

Food Allergy — Lactose Intolerance — 9 to 18 years of age

No

$59, subject to subsection 2 (6)

22.

Food Allergy — Lactose Intolerance — 19 to 50 years of age

No

$30, subject to subsection 2 (6)

23.

Food Allergy — Lactose Intolerance — 51 years of age or older

No

$45, subject to subsection 2 (6)

24.

Food Allergy — Wheat

No

$97, subject to subsection 2 (7)

25.

Gestational Diabetes

No

$102, subject to subsection 2 (4)

26.

HIV/AIDS

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

27.

Huntington Disease

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

28.

Hyperlipidemia or Hypercholesterolemia

No

$51, subject to subsection 2 (4)

29.

Hypertension

No

$86, subject to subsection 2 (4)

30.

Inadequate lactation to sustain breast-feeding or breast-feeding is contraindicated — Where infant is lactose tolerant

No

$145

31.

Inadequate lactation to sustain breast-feeding or breast-feeding is contraindicated — Where infant is lactose intolerant

No

$162

32.

Lupus

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

33.

Malignancy

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

34.

Multiple Sclerosis

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

35.

Muscular Dystrophy

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

36.

Osteoporosis

No

$38

37.

Ostomies [e.g., jejunostomy, ileostomy]

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

38.

Pancreatic Insufficiency

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

39.

Parkinson Disease

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

40.

Prader-Willi Syndrome

No

$200, subject to subsection 2 (4)

41.

Renal Failure (GFR < 30)

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

42.

Renal Failure — Pre-Dialysis (GFR <30)

No

$52, subject to subsection 2 (8)

43.

Renal Failure — Peritoneal/Hemodialysis

No

$88, subject to subsection 2 (8)

44.

Rett Syndrome (BMI < 18.5)

No

$88, subject to subsection 2 (9)

45.

Short Bowel Syndrome

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)

46.

Ulcerative Colitis

Yes

$191 or such higher amount as may be permitted in accordance with subsection 2 (2)