LCSA - Opt-Out 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 Opt-Out Application

Fall deadline to submit applications
September 27^th, 2023

Eligible students who have comparable Health and Dental coverage and meet the following eligibility criteria may apply to opt out of the benefits before the applicable term deadline.

<

Eligibility Criteria

There are 2 circumstances for opting out of the Student Health and Dental Plan:

1New Students

Students starting an eligible program who have comparable Health and Dental coverage from their parents, spouse, government, job, or band may apply to opt out of the plan by the applicable term deadline.

2Returning Students

Returning students enrolled in an eligible program who are attending school on the anniversary of starting their program and have comparable Health and Dental coverage from their parents, spouse, government, job, or band may apply to opt out of the plan by the applicable term deadline.

Things to consider when thinking of opting out:

A parents' insurance plan will stop covering you if you are a part-time student over the age of 21 or a full-time student over the age of 25.
You can coordinate 2 benefit plans and increase your coverage up to 100%! Find out more Coordination of Benefits
What is in the best interest of my overall health & wellbeing?
Does my existing coverage meet all of my needs?
The only time you can re-enroll in the student plan is on the anniversary date of the term you opted out of the plan OR within 30 days of losing your comparable coverage.

Opt-Out Audit

If your application has been chosen for an audit, you will receive by email, a request from the benefit plan office to provide documentation to confirm your existing comparable Health and Dental coverage. Please provide the documentation only if you receive a request to do so. If you do not provide the supporting documentation by the deadline indicated on the email request, the opt-out application will not be processed.

Steps to Submitting a Health and Dental Opt-Out Application:

1 Student Information

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

2 Health Plan Opt-Out

Scroll down and check yes/no if you wish to opt-out of the health portion of the student plan. Provide the comparable insurance company name and policy number. Click NEXT.

3 Dental Plan Opt-Out

Scroll and check yes/no if you wish to opt out of the dental portion of the student plan. Provide the comparable insurance company name and policy number. Click NEXT.

4 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.

5 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.

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 Opt-Out Form

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Date of Birth

Date Month Field Date Day Field Date Year Field

Mailing Address

City

Province

Postal Code

Phone Number

Phone Area Number Phone Local Number Phone Digits

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

Required Direct Deposit Information

Please enter your financial institution's Transit Number, Institution Number, and Account Number. (*mandatory fields)

** Please do not enter any dashes or spaces **

Transit #

Institution #

Account #

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

Follow Us!