SD78 – Trustees
EXTENDED HEALTH CARE
Insurer: Pacific Blue Cross
Policy Number: 20078
Reimbursement
80% until $1,000 paid
per person per calendar year, 100% thereafter
Annual deductible
$25
Lifetime maximum
$500,000 per lifetime
Termination Age
The earlier of the following dates: Termination of employment, retirement
Medical referral travel benefit
N/A
Survivor extension
Yes, coverage will continue to the last day of the month in which the Member dies.
Prescription Drugs
Drug formulary
Prescription Required
Pay-direct drug card
No
Per prescription deductible
$0
Sexual dysfunction
N/A
Oral Contraceptives
Not 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)
Covered – Requires referral by a Physician
Hearing aids
$500 for adults, and $900 for dependent children in a 60 month period
Other services and supplies (subject to reasonable and customary limits as defined by insurer)
Covered
Orthopedic shoes
when prescribed by a Physician or podiatrist as medically necessary, charges for one pair of custom fitted orthopedic shoes or orthotics, and replacements necessitated by normal wear and tear
Orthotics
when prescribed by a Physician or podiatrist as medically necessary, charges for one pair of custom fitted orthopedic shoes or orthotics, and replacements necessitated by normal wear and tear
Vision Care
Maximum
$150 every 24 months
Eye exams
Charges for routine eye examinations every 2 Calendar years to a payable maximum of $100 when performed by a Physician or optometrist for persons between the ages of 19 and 64
Prescription sunglasses
Not Covered
Paramedical Services
Massage therapist
No calendar year limit
Physiotherapy
No calendar year limit
Chiropractor
$200 per calendar year
Psychology
$250 per calendar year
Naturopath
$200 per calendar year
Podiatry
$200 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: 20078
Annual deductible
N/A
Dental fee guide
PBC Schedule 2
Specialist fee guide
Fee Guide +10%
Termination Age
The earlier of the following dates: Termination of employment, retirement
Survivor extension
Yes, coverage will continue to the last day of the month in which the Member dies.
Basic Services
Reimbursement
100%
Maximum
N/A
Adult check-up
As indicated in the Fee schedule/Fee guide
Child check-up
As indicated in the Fee schedule/Fee guide
Endodontic/Periodontic Services
Reimbursement
100%
Maximum
N/A
Major Restorative Services
Reimbursement
80%
Maximum
No maximum. Only 1 inlay, onlay, or another major restorative service involving the same tooth will be covered in a 5 year period.
Orthodontic Services
Reimbursement
50%
Maximum
$1,750/Lifetime
Age limit
N/A
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