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
Orthopedic 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