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

Othopedic 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