For all provinces other than Quebec, you can generate a sticker with this proposed statement. The sticker would require PAAB review. In the context of that review, we can assess the sticker placement.
RAMQ (i.e. for Quebec) you’ll need to include the coverage criteria (assume that there are such criteria). There will also be other requirements unique to the Quebec as conveyed in this link: http://www.paab.ca/Advisory_regarding_use_of_RAMQ_in_APS.pdf