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myBenefits



myBenefits at a Glance


The highlights below are provided as general information. Coverage for eligible costs are based on the contract detail. Reasonable and customary rates will be applied. 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 Formulary with a generic rider.
(please click Prescription Drugs for details)

Vision:
Reimbursed at 100% to a maximum of $80 for glasses or contact lenses every 24 months. Limit of 1 eye exam every 24 months based on reasonable and customary charges.
(please click Vision for details)

Health Practitioners:
The services of paramedical practitioners are reimbursed at 80% to a specified maximum. Practitioners must be registered and licensed in their field of practice.
(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 Coverage:
Exams covered at 100% (Select Dentists) or 70% (Alternate Dentists) once per benefit year. Overall plan maximum of $750 per benefit year.
(please click Dental for details)

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

Travel Insurance:
$2 million of coverage for emergencies and illnesses while travelling.
(please click Travel Insurance 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.

Supplemental Health




Ambulance
Your plan covers 80% to a maximum of $250 per occurrence for ambulance for licensed ground ambulance or emergency air service that transports the patient to the nearest hospital equipped to provide the required treatment when the physical condition of the patient prevents the use of another means of transportation. If the patient requires the services of a registered nurse during the flight, the services and return airfare for a registered nurse are covered.
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. Practitioners must be registered and licensed in their field of practice.

The services of the following practitioners are covered at 80% for $20 per visit to a maximum of $300 per practitioner, per benefit year.
• physiotherapist*
• registered massage therapist*
• chiropractor, including 1 x-ray examination per benefit year
• speech language pathologist*
• osteopath, including 1 x-ray examination per benefit year
• naturopath
• podiatrist or chiropodist, including one x-ray examination per benefit year

The services of the following practitioners are covered at 80%, to a maximum of $500 per benefit year.
• psychologist or social worker

*physician’s prescription/referral required for indicated services

For Online Video Counselling you can submit your receipts online or with our paper form for reimbursement.
Medical Services & 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.

Medical Equipment
Your plan covers 80% of 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
• wheel chair repairs (lifetime maximum of $250)
• walkers
• hospital beds
• traction kits

Braces, Crutches, Splints, Trusses
Your plan covers 80% of reasonable and customary charges when prescribed by a physician and are not solely for athletic use for braces, crutches, splints, and trusses.

Prosthesis
Your plan covers 80% of reasonable and customary charges when prescribed by a physician for artificial limbs or other prosthetic appliances.

Diabetic Supplies
Your plan covers 80% to a maximum of $150 during a 5 year period for blood glucose monitors.

Orthopaedics*
Your plan covers 80% up to a maximum of $150 per benefit year for Custom-Made Orthopaedic shoes when they are 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. Modifications, repairs and adjustments to custom-made orthopaedic shoes are covered without a prescription.

*IMPORTANT It is strongly recommended that a pre-determination/estimate be submitted to Great-West Life to ensure that the guidelines set out by Great-West Life for the payment of Orthopaedics are met and to confirm that your claim would be eligible.
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 of the cost of the services of a dental surgeon, limited to the fees provided in the current General Practitioners fee guide, 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. Services must be performed within 12 months of the accident. If a dental accident occurs, the health plan’s dental accident provision will pay benefits before the dental plan.

Treatment must be completed within 12 months of the impact. If treatment is scheduled to occur more than 90 days after the impact, a treatment plan must be submitted to the insurer before the end of the 90 day period.

Prescription Drug

Your drug plan covers 80% of the cost of most medications legally requiring a prescription to a maximum of $3,000 per benefit year.

Your drug plan includes coverage of Smoking Cessation Products that legally require a prescription. Reimbursed at 80% to a lifetime maximum of $500.

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 by the Formulary are not effective in treating the 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 NAITSA Service Hub and must be completed by your physician. Completed forms may be returned to NAITSA Service Hub or can be faxed directly to the insurance company.

Request for Coverage of Exception Status Drug form

Vision

Your plan covers 100% of the cost of eye examinations by an ophthalmologist or optometrist limited to one examination, in a 24 month period, based on reasonable and customary charges.

Your plan covers 100% of cost for the purchase of eyeglasses and/or contact lenses to a maximum of $80, once during a 24 month period, based on reasonable and customary charges.

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.

Select and Alternate Dental Providers
The dental benefits provided under the Select Dental Provider option are provided through a specific network of dental centres. If you choose one of the Select Dental Providers, your diagnostic & preventive dental benefits will be reimbursed at the level indicated below. Please contact the NAITSA Service Hub or use the "Find a Practitioner" option for a list of Select Dental Providers* where services can be received.

If you choose an Alternate Dental Provider (a dentist or dental centre not on the Select Dental Provider list) your diagnostic & preventive dental benefits will be reimbursed at the level indicated below.

*Please note: the list of Select Dental Providers may be subject to change.

If you need to cancel your dental appointment, 24 hours notice is expected. If you do not give 24 hours notice, the dental office may charge a fee which is not covered under the plan.

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.


Diagnostic & Preventative
Your plan covers 100% for Select Dentists or 70% for Alternate Dentists for diagnostic and preventative procedures including:
• recall examination, 1 per benefit year
• complete series of x-rays, 1 in any period of 36 months
• bitewings, not more than 4 films per benefit year
• polishing, 1 unit per benefit year
• scaling, 2 units per benefit year
• fluoride, under 19 years of age, 1 treatment per benefit year
Minor Restorative
Your plan covers 80% for services associated with dental health restoration, including:
• space maintainers and maintenance, under 15 years of age
• amalgam and tooth coloured fillings, 1 per tooth in any period of 24 months
• stainless steel and plastic full coverage restorations, under 15 years of age, 1 per tooth in any period of 36 months
• recementation of fixed prosthetics
• denture adjustments and repairs
• relining, rebasing and tissue conditioning, one treatment in any period of 36 months
• pit and fissure sealants, under 19 years of age, 1 replacement per tooth, per lifetime, on permanent molars
Oral Surgery
Your plan covers 50% for services associated with surgical extractions, including:
• extractions, not more than 2 wisdom teeth per benefit year
• anaesthesia, eligible when done in conjunction with Oral Surgery
• panoramic x-ray, 1 in any period of 36 months
Endodontic
Your plan covers 50% for endodontic services including:
• root canal therapy
Periodontic
Your plan covers 50% for periodontic services including:
• additional scaling and/or root planing, maximum 2 units per benefit year
Major Restorative
Your plan covers 15% for major restorative services including:
• crowns
• bridges
• dentures

Replacement of an existing crown, bridge or dentures is an eligible expense if the replacement is required to replace an existing crown, bridge or denture which was installed 5 years before the replacement.

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 benefit is based on a maximum benefit of $5,000.

Tutorial*

Your plan covers 80% up to $15 per hour to a maximum of $2,000 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.

Travel Insurance

Emergency Out of Country Travel Insurance
Your plan covers 100% up to a maximum of $2,000,000 per lifetime of medical expenses incurred as a result of a medical emergency arising while you are traveling outside Canada for vacation, business or education purposes. To qualify for benefits, you must be covered by the government health plan in your home province. For additional details on this benefit download your Travel Assist Brochure.

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, Workplace Safety and Insurance 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 is ordinarily a resident 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) expenses incurred on a non-emergency or referral basis;
19) immunizations and vaccines (Hepatitis B will be covered, except for Recombivax HB preservative free - DIN 02245976 and DIN 02245977); or
20) 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 or treatment for which the insured is not legally obliged to pay;
8) dental care, treatment or supplies primarily for cosmetic purposes;
9) any appointments not kept or for the completion of claim forms;
10) any dental treatment that has as its purpose the correction of temporomandibular joint dysfunction;
11) any services or supplies for implantology, including tooth implantation and surgical insertion of fabricated implants;
12) any endodontic treatment commencing prior to the date on which the Insured becomes insured under this provision, except as required to be consistent with the terms of the applicable Extension of Insurance on Replacement of this Policy section;
13) replacement of mislaid, lost or stolen appliances;
14) any crowns placed on teeth that are not functionally impaired by incisal or cuspal damage;
15) any crowns, dentures, and bridges for which tooth preparations were made prior to the date on which the Insured becomes insured under this provision, except as required to be consistent with the terms of the applicable Extension of Insurance on Replacement of this Policy section;
16) charges that are in excess of the fees stated in the Alberta Dental Association General Dentist Fee Guide applicable to this benefit;
17) where coverage for services is provided under any government plan;
18) where services would be provided without charge in the absence of this policy; or
19) any other exclusions identified in the policy contract.

Service Members


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