SD74 – Trustees

EXTENDED HEALTH CARE

Insurer: Pacific Blue Cross

Policy Number: 20074

Reimbursement

75% until $1,000 paid per person, then 100%;

Annual deductible

$50 per person or $100 per family each calendar year

Lifetime maximum

$3,000,000

Termination Age

The earliest of the following dates: July 31st following the date the Member attains age 70, the last day of the month in which the Member retires, or when the Member dies.

Medical referral travel benefit

N/A

Survivor extension

N/A

Prescription Drugs

Drug formulary

Prescription Required

Pay-direct drug card

No

Per prescription deductible

$0

Sexual dysfunction

N/A

Oral Contraceptives

Covered

Fertility

Not covered

Smoking cessation

Not covered

Medical Services & Supplies

Medi-assist

Included

Emergency out-of-province reimbursement

100%

Emergency out-of-province maximum

N/A

Hospital

Private or Semi-Private

Private duty nursing (including in-home)

$10,000 per calendar year

Hearing aids

$400 in a 5 Calendar year period for Dependent children only

Other services and supplies (subject to reasonable and customary limits as defined by insurer)

Covered

Othopedic shoes

$400 per adult and $200 per Dependent Child per calendar year

Orthotics

Not Covered

Vision Care

Maximum

$200 every 24 months

Eye exams

1 every 24 months – separate from vision care maximum

Prescription sunglasses

Covered

Paramedical Services

Physiotherapy

$20 per visit to a maximum of $250 per calendar year combined with physiotherapist

Massage therapist

$20 per visit to a maximum of $250 per calendar year combined with massage therapist

Naturopath

$20 per visit to a maximum of $200 per calendar year combined with naturopath

Psychology

$100 per calendar year

Chiropractor

$20 per visit to a maximum of $200 per calendar year combined with chiropractor

Podiatry

$20 per visit to a maximum of $100 per calendar year

Acupuncture

$100 per calendar year

Speech therapy

$100 per calendar year

Osteopath

N/A

Christian Science

N/A

DENTAL CARE

Insurer: Pacific Blue Cross

Policy Number: 20074

Annual deductible

N/A

Dental fee guide

PBC Schedule 2

Specialist fee guide

Professional association fee guide

Termination Age

July 31st following the Employee’s 65th birthday

Survivor extension

Yes, to a maximum of 6 months

Basic Services

Reimbursement

100%

Maximum

N/A

Adult check-up

One per 5 months

Child check-up

One per 5 months

Endodontic/Periodontic Services

Reimbursement

Covered in Basic Services

Maximum

N/A

Major Restorative Services

Reimbursement

60%

Maximum

N/A

Orthodontic Services

Reimbursement

50%

Maximum

N/A

Age limit

Up to and including age 18.

GROUP LIFE

Insurer: N/A

Policy Number: N/A

Schedule

N/A

Maximum

N/A

Termination age

N/A

Age reduction

N/A

Waiver of premium definition

N/A

Optional life

N/A

GROUP ACCIDENT

Insurer: N/A

Policy Number: N/A

Principal sum

N/A

Maximum

N/A

Optional Accident

N/A