LCSA - Family Add-On Form

Student Health & Wellness!mystudentplan is a benefits plan for students and can provide coverage for prescription drugs, vision care, dental care, mental health counseling, and more. The plan is designed to supplement provincial health insurance and provide additional access to medical services.

Online Forms

Are you covered by a comparable plan? Do you wish to cover your dependents? Or have you opted out of the plan and wish to be re-enrolled? Eligible Students may submit their online forms.

Health and Dental Family Add-On Application

Fall deadline to submit applications
September 27^th, 2023

Eligible students who meet the following eligibility criteria may apply to extend their benefits to their dependents before the applicable term deadline.

Health and Dental insurance fees on the student account are for the student only. Students must apply and pay additional fees to have their family members added each benefit plan year.

Eligibility Criteria

There are 2 circumstances for adding family members to the Student Health and Dental Plan:

1 Academic Enrollment

Eligible students who wish to extend their benefits to their dependents may apply by the applicable term deadline according to the college enrollment:

New Students: Students starting an eligible program and enrolled in the health and dental plans who wish to extend their plan to their eligible family members may apply by the applicable term deadline.
Returning Students: Returning Students enrolled in an eligible program, enrolled in the health and dental plans, and attending school on the anniversary of starting an eligible program who wish to extend their plan to their eligible family members may apply by the applicable term deadline.

If you miss the term or anniversary deadline, your next opportunity to add dependents would be the next anniversary of starting your program.

Fall 2023 deadline is September 27^th, 2023

2 Lifestyle Change

Students enrolled in the plan who have a lifestyle change such as getting married, meeting the twelve-month co-habitation requirement for common law status, or birth/adopting a child, who wish to extend their plan to their dependents may apply within 30 days of lifestyle change.

To apply, please email proof of Lifestyle Change to the Benefit Plan Office at lethbridgeplan@mystudentplan.ca. If you are eligible to add family members, the office will send a link for the application.

Documentation includes a marriage certificate, birth certificate, or adoption documents.

If you miss the lifestyle change deadline, your next opportunity to add dependents would be the next anniversary of starting your program.

Deadline to submit applications
within 30 days of lifestyle change

Family Add-On Fees:

ONE FAMILY MEMBER		TWO OR MORE FAMILY MEMBERS
Health	$160.00	Health	$200.00
Dental	$190.00	Dental	$270.00
Health & Dental	$350.00	Health & Dental	$470.00

The student understands the Family coverage provided to the plans must be renewed each Benefit Year.
Family Add-on Fees are subject to change without notice.
Family Add-On fees are not included in your tuition and can be paid by the link provided on the approval email or at the benefit plan office.
The Family Add-on fees cover 12 months of coverage.
Family Add-on fees are non-refundable.

Important notes:

You can only extend your plan to your spouse or partner and your children. Parents, grandparents, and siblings are not eligible dependents to extend your plan. Please check the eligible dependents.
The family coverage is the same plan as the student with the exception of the Accidental Death & Dismemberment, Critical Illness, Tuition, and Tutorial benefits, these benefits apply to the Student Only.
The family fees provide the same 12 months of coverage as the student coverage provided the family add-on is applied for each benefit year the student remains eligible to be covered. The effective date of coverage is the 1^st day of the month your program begins.
Family Add-On requests & fees are not automatically renewed and must be applied for, approved, and paid each benefit year.
There is a 45-60-day validation period from the start of the student's program. During this time, you would pay all eligible Health and Dental expenses and keep the receipts and once the enrollment process is complete, you can submit claims online for reimbursement.
Each family member uses the same benefit card the student uses, and the card must have the student's information (full name and student ID) completed on it.
Family Add-on fees are non-refundable.
NO EXCEPTIONS will be made if the application or payment is missed. It is the student's responsibility to check their emails regarding the application during the enrollment period and prior to the applicable deadline.
Once you complete the Family add-on form, you will receive an automated email confirmation. Please keep this email for your records as it is your only proof of you submitting a Family Add-on request.

Steps to Submitting a Family Add-On Application:

1 Student Information

Complete this section below providing true and correct information. Click NEXT.

2 Dependent Information

Scroll down and check Spouse/Child/Children according to the members you wish to add. Provide full name, initials, gender, and date of birth for each member. Click NEXT.

3 Read and Agree to the Terms and Conditions

Click on the checkbox to indicate that you agree to the Terms and Conditions agreement. Click SUBMIT to finish your application.

4 Confirmation email

Check your email and verify if you have received the confirmation email. If you do not receive this email, you must resubmit the form.

5 Application status

You will receive an email with the status of your application.

6 Pay fees online

If your application is approved, you will receive a link to pay the applicable fees with your credit card, and the deadline for payment is to be received.

Add donotreply@gallivan.ca to your address book. Please do not reply to this email.

Questions? Please contact your Benefit Plan Office: lethbridgeplan@mystudentplan.ca

Health and Dental Family Add-On Form

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Sex

FMU

Date of Birth

Date Month Field Date Day Field Date Year Field

Phone Number

Phone Area Number Phone Local Number Phone Digits

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

Online Forms Deadline
Submit your online Family Add-On, Opt-Out, or Opt-In applications by September 27^th, 2023

Plan Card Generator
Generate your Plan Card and use it where direct billing to Canada Life is available.

Prescription Search Tool
Find out if your prescription drugs are covered by the student plan.

Plan Claims
Learn more about submitting online or manual claims to Canada Life to get your refund.

LCSA Benefits Plan Office

Email: lethbridgeplan@mystudentplan.ca
Phone: 403 320-3202 Extension 5310
Address: Room CE1350
3000 College Drive South
Lethbridge, Alberta. T1K 1L6

General Inquiries Line

Monday to Friday from 6:00am to 5:00pm MST

Phone: 1-877-746-5566 Ext. 7249

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