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myBenefits

Coverage for eligible costs is based on the contract detail. Select the benefit for additional coverage details.

Prescription Drug

Reimbursed at 80% to a maximum of $3,000 per benefit year.
Based on the National Drug Formulary with a generic rider.

The maximum amount payable to an eligible brand name drug will be limited to the lowest priced item in the appropriate generic category.

IMPORTANT! Advise your doctor and pharmacist that you are on the National Formulary.

The National Formulary is a specific list of drugs that are eligible for reimbursement under your drug benefit. Formularies are developed to ensure that prescription drugs are available on a cost-effective basis. It covers approximately 85% of the most frequently prescribed drugs. Formularies are reviewed regularly and as a result, updates are made on an ongoing basis.

Exception Process: In the event that the drugs covered are not effective in treating your condition, an exception process is in place. To be eligible for an exception, you must have tried one alternative drug listed on the Formulary. An exception drug request form is available below or from the Benefits Plan Office and must be completed by your physician. Completed forms may be returned to the Benefits Plan Office or can be sent directly to the insurance company.

Request for Coverage of Exception Status Drug form

Vision

Reimbursed at 100%, combined maximum of $160 for one eye exam, glasses or contact lenses every 24 months.

Your plan covers 100% the cost of one eye examination, eyeglasses or contact lenses by an ophthalmologist or optometrist, limited to a combined maximum of $160 in a 24 month period for a cost that is considered reasonable and customary.

Supplemental Health




Ambulance
Your plan covers 80% of reasonable costs and for an authorized ambulance or emergency service that transports the patient to the nearest hospital equipped to provide the treatment required when the patient's physical condition prevents the use of another means of transportation.
Practitioners
Student benefits are payable after any Provincial Health Care benefits have been exhausted. This plan does not cover user fees. Student specific rates are available for some of the indicated services, information can be found in Select Savings.

The services of the following practitioners are covered at 80% for $20 per visit to a maximum of $300 based on reasonable and customary charges, per practitioner, per benefit year.

• physiotherapist*
• registered massage therapist*
• speech therapist*
• psychologist or social worker*
• chiropractor, including 1 x-ray examination per benefit year
• osteopath, including 1 x-ray examination per benefit year
• naturopath

*physician's prescription/referral required for indicated services

Medical Equipment & Supplies
It is recommended that an application for pre-approval be submitted to the insurer for any item that would be claimed under the Medical Services & Supplies benefit. A physician's prescription is required. Pre-authorization is suggested.

Medical Equipment
Your plan covers 80%, based on reasonable and customary charges for eligible equipment when prescribed by a physician. Eligible durable equipment includes, but is not limited to, items such as:

• wheel chairs (repairs to a lifetime maximum of $250)
• walkers
• hospital beds
• braces, crutches, splints & trusses
• artificial limbs & eyes
• other approved prosthetic devices

Orthopaedics*
Your plan covers 80% to a maximum of $150 per benefit year for custom-made orthopaedic shoes, repairs and modifications when required for the correction of deformity of the bones and muscles and provided they are not solely for athletic use and are prescribed by a physician, podiatrist, chiropodist, or chiropractor.

*IMPORTANT It is strongly recommended that a pre-determination/estimate be submitted to Canada Life to ensure that the guidelines set out by Canada Life for the payment of Orthopaedics are met and to confirm that your claim would be eligible.
Trusses, Crutches, Splints, and Braces
Your plan covers 80% of reasonable and customary charges for braces, provided they are not solely for athletic use. It is recommended that an application for pre-approval be submitted to the insurer.

Prosthesis
Your plan covers 80% of reasonable and customary charges for artificial limbs or other prosthetic appliances. It is recommended that an application for pre-approval be submitted to the insurer.

Dental Accident
IMPORTANT! Dental Accident Pre-determination: An estimate for all dental accident services MUST be submitted to the health plan insurer. If you go ahead with treatment without a pre-determination being approved, you are doing so at the risk of the expenses being yours.

The plan covers 80%, to a maximum of $1,000 per occurrence for the cost of the services of a dental surgeon, including dental prosthesis, required for the treatment of a fractured jaw or accidental injuries to natural teeth or jaw if caused by external, violent and accidental means. Provided the services are performed within 12 months of the accident but excluding services required in conjunction with such injuries due to a condition that existed before the accident. Implants and treatment related to implants are not covered. If a dental accident occurs, the health plan's dental accident provision will pay benefits before the dental plan.

In the event of a dental accident, you must complete a Standard Dental Association claim form. When making a claim, be sure to attach all original receipts to the claim form. The claim form can be mailed directly to the insurance company.

Dental

Payment of dental benefits is based on the General Practitioners Dental Association suggested fee guide or the Insurance Reimbursement Rate set by the Canadian Life and Health Insurance Association Inc. (CLHIA) when a fee guide is not available. For services provided by a dental specialist, payment is based upon the General Practitioners Dental Association suggested fee guide.

Alternate Benefit - When there are two or more courses of treatment available to adequately correct a dental condition, reimbursement may be based on the cost of the least expensive treatment, which provides adequate care to the Insured.

IMPORTANT! Please submit a pre-determination/pre-authorization to the insurance carrier prior to treatment of specialist services and any treatment plan exceeding $500.

Your plan covers up to a maximum of $750 per benefit year.


Other Insurances

Accidental Death & Dismemberment*
Your plan provides coverage for the loss of life or limb and for paralysis caused by an accident. The amount of yout life benefit is $5,000. Please contact Gallivan for a complete schedule of losses.

Tutorial*
Your plan covers 80% up to $15 per hour to a maximum of $2000 per benefit year for private tutorial service if the student is confined to home or hospital for a minimum of 15 consecutive school days.

*Applicable to the Student only. Family members are not eligible for reimbursement of Accidental Death & Dismemberment and Tutorial benefits.

Personal Health Risk Assessment

The Personal Health Risk Assessment can be used to create a health profile, build an action plan to support your health and wellness needs and track progress.
Watch a short video about Personal Health Risk Assessment.   

Exclusions

Limitations and Exclusions to Extended Health Benefits
No benefit is payable for:
1) expenses for which benefits are payable under a Workers' Compensation Act or a similar statute;
2) expenses incurred due to intentionally self-inflicted injuries;
3) expenses incurred due to civil disorder or war, whether or not war was declared;
4) expenses for services and products, rendered or prescribed by a person who ordinarily resides in the patient's home or who is related to the patient by blood or marriage;
5) expenses for which benefits are payable under a government plan;
6) expenses for benefits which are legally prohibited by the government from coverage;
7) out-of-province expenses for elective (non-emergency) medical treatment or surgery;
8) expenses for drugs which, in the insurer's opinion, are experimental;
9) expenses for dietary supplements, vitamins and infant foods;
10) expenses for contraceptives (other than oral);
11) drugs for the treatment of erectile dysfunction;
12) expenses for drugs if they are used for the treatment of infertility;
13) expenses for the services of a homemaker;
14) expenses for items purchased solely for athletic use;
15) dental expenses, except those specifically provided under eligible expenses for treatment of accidental injuries to natural teeth;
16) utilization fees which are imposed by the Provincial Health Care Plan for the use of a service;
17) expenses for the regular treatment of an injury or disease which existed before the member's or dependant's departure from his/her province of residence;
18) preventative immunization vaccines and toxoids; or
19) any other exclusion identified in the policy contract.

Limitations and Exclusions to Dental Benefits
No benefit is payable for:
1) any cause for which the insured may apply for and receive protection, exemption or compensation under any Workers' Compensation Act;
2) self-inflicted injuries while sane or insane;
3) war, insurrection or hostilities of any kind, whether or not the insured was a participant in such actions;
4) participation in any riot or civil commotion;
5) committing or attempting to commit a criminal offence or provoking an assault;
6) any group or policyholder sponsored dental care or treatment;
7) any dental care, treatment or supplies primarily for cosmetic purposes;
8) failing to keep scheduled appointments;
9) file transfers, the completion of claim forms or other documentation;
10) any dental treatment for the correction of temporomandibular joint dysfunction;
11) expenses for treatment of root canal therapy, inlays, onlays, crowns, veneers, and bridges started prior to becoming an insured member/dependant under this plan;
12) replacement of mislaid, lost or stolen appliances;
13) expenses for crowns placed on a tooth not functionally impaired by incisal angle or cuspal damage;
14) any charges incurred for other than metal only crowns or pontics, posterior to the second bicuspid tooth;
15) expenses for full mouth reconstructions for vertical dimension correction or to repair or restore teeth damaged or worn due to attrition or vertical wear or to restore occlusion;
16) any services or supplies for implantology, including tooth implantation and surgical insertion of fabricated implants;
17) any dental procedure which is not listed in the descriptions of dental benefits indicated herein;
18) charges that are in excess of the fees stated in the Dental Association General Dentist Fee Guide applicable to this benefit;
19) where coverage for services is provided under any government plan;
20) where services would be provided without charge in the absence of this policy; or
21) any other exclusions identified in the policy contract.

myBenefit at a GLance

The highlights below are provided as general information. Coverage for eligible costs is based on the contract detail. Select the benefit for additional coverage details.

Ambulance
Reimbursed at 80% to a maximum of $250 per occurrence.
(please click Supplemental Health for details)

Prescription Drugs
Reimbursed at 80% to a maximum of $3,000 per benefit year.
Based on the National Drug Formulary with a generic rider.
(please click Prescription Drug for details)

Vision
Reimbursed at 100%, combined maximum of $160 for one eye exam, glasses or contact lenses every 24 months.
(please click Vision for details)

Health Practitioners
The services of paramedical practitioners are reimbursed at 80% to a maximum of $20 per visit. Each service has an overall plan maximum of $300 based on reasonable and customary charges, per benefit year.
(please click Supplemental Health for details)

Medical Equipment & Supplies
Reimbursed at 80%. A physician's prescription is required. Pre-authorization is suggested.
(please click Supplemental Health for details)

Dental Accident
Reimbursed at 80% of eligible expenses to a maximum of $1,000 per accident,
services must be performed within 12 months of the accident.
(please click Supplemental Health for details)

Dental Coverage
Exams covered at 70% once per benefit year. Overall plan maximum of $750 per benefit year.
(please click Dental for details)

Accidental Death & Dismemberment
$5,000 loss of life benefit.
(please click Other Insurances for details)

Tutorial
After 15 days of confinement due to illness or injury.
(please click Other Insurances for details)

NOTE: In the event of any discrepancy between the information herein and our contract with the insurer, the terms of the contract will apply.

Service Members


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