|
Schedule
of Benefits
Benefit
Level 03 (default)
|
MEMBER LIFE
INSURANCE |
|
|
All Eligible
Members |
Amount
of Insurance |
|
Under age 65 |
$ 75,000 |
|
Age 65 to age
69 |
$ 37,500 |
|
Age 70 and
over |
$
5,000 |
MEMBER
& FAMILY DENTAL BENEFIT
Co-Insurance
(paid by the Plan): 80%: of all eligible Basic & Restorative expenses.
Maximum: Basic &
Restorative (combined) - $1,500 per individual per plan year.
Provincial Fee
Guide: Reimbursement will be based on the Current Dental Association Fee
Guide for Dental Practitioners of:
- the province
where charges are incurred, if incurred in Canada; or
- the covered
person’s home province, if incurred outside of Canada; or
- for Plan Members
who reside primarily outside of Canada, payment will be based on
reasonable and customary charges in Canada.
At
age 75 you qualify for the Golden Level, your dental benefits and those
of your dependents will terminate when you reach age 75 unless you are
receiving producer contributions while working. Producer
contribution balances up to a maximum of $3,967.31 will be placed in a
health spending benefit and can be used for reimbursement of any
qualifying medical expense.
MEMBER &
FAMILY HEALTH CARE BENEFIT
|
Co-Insurance
(paid by the plan): |
80%: of all
eligible expenses (except 100% of all eligible out of country
emergency expenses). |
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|
Maximum -
Eligible Members: |
|
| |
|
|
Under age 70: |
- Unlimited
(subject to appropriate benefit maximums shown in this booklet).
|
|
Age 70 to age
74: |
- All Health
Care Benefit expenses (except Emergency Out of Country Coverage,
which terminates on March 31st following the Member’s 70th
birthday) to an annual maximum of $3,000 per person starting on
the April 1st following the Member’s 70th birthday.
|
|
Age 75 or
over: |
- At
age 75 you qualify for the Golden Level, your health care
benefits and those of your dependents will terminate when you
reach age 75 unless you are receiving producer contributions
while working. Producer
contribution balances up to a maximum of $3,967.31 will be
placed in a health spending benefit and can be used for
reimbursement of any qualifying medical expense.
|
| |
|
|
HEALTH CARE
BENEFITS |
BENEFIT
MAXIMUMS |
| |
|
|
Prescription
Drugs:
|
- Manulife Financial: Pay Direct
Drug Card,
- drugs
available only by prescription, and with the following limits:
|
| |
a)
Maximums: |
- dispensing
fee not covered
- to
reimburse the least costly course of treatment, whether it is a
generic or brand name drug
- the
cost of over-the-counter drugs are not covered regardless of
whether they have been prescribed or not
|
| |
b)
Maintenance
Drugs: |
- 90 day
supply at one time, once classed as a maintenance drug (no dispensing fee)
|
|
Vision Care: |
- Prescription
lenses (including contact lenses), frames, and the fitting of
glasses; up to $300 for member, $150 for dependents in any consecutive 24 month period
- Contact
lenses for certain specified conditions; up to $200 every 24
consecutive months
|
| Hospital
(in Canada): |
- Semi-private
Hospital Room and Board charges in excess of ward accommodation
up to $10,000 per Plan year
|
|
Convalescent
Hospital: |
- Semi-private
room and board charges in excess of ward accommodation in a
convalescent home or rehabilitation hospital for a maximum of
180 days per disability
|
|
Nursing (out
of hospital): |
- Private
duty nursing for acutely ill patients when not confined to a
hospital, based on a minimum of one four hour shift per day to a
maximum of $5,000 per Plan year
|
| Victorian
Order of Nurses: |
- To a
maximum of $400 per Plan year
|
|
Medical
Practitioners: |
- Up to $600
each per Plan year for licensed/registered medical practitioners
- Practitioners
must meet Income Tax Act and Provincial Legislation requirements
|
|
Eye
Examinations: |
- When no
coverage exists under the medicare plan in your province of
residence, to a maximum of $40 per examination once every 24
consecutive months
|
|
Hearing Aids: |
- Purchase,
repair or replacement to a maximum of $600 every 5 consecutive
Plan years
|
| |
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Orthopaedic Appliances, Custom-made Orthotics & Orthopaedic
Shoes (when the shoes are attached to and form part of a brace): |
- When
prescribed to a maximum of $450 per individual per Plan year
|
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|
|
Orthopaedic Shoes (when not
attached to or forming part of a brace): |
- When
prescribed a to a
maximum of $300 per individual per Plan year
|
|
|
|
Custom-made Orthotics: |
- When
prescribed a to a
maximum of $450 per individual every 2 Plan years
|
| |
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Prosthetic
Appliances: |
- For initial
purchase up to a lifetime maximum of $10,000
- Replacements
are only eligible when needed due to changes in physical
condition
|
| |
|
|
I U D ’s: |
- When
prescribed by a licensed physician to a maximum of 2 per Plan
year
|
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Fertility
Drugs & InVitro Drugs to be covered: |
- A
predetermination for all expenses over $500 should be done prior
to treatment to determine which expenses will be covered. Up to a
combined lifetime maximum of $5,000. Eligible
Fertility & InVitro procedures may be payable from your
health spending account if applicable.
|
| |
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Anti-Smoking
Aids: |
- Available
by prescription only and up to a lifetime maximum of $500
|
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| Accidental
Dental: |
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Out
of Province Benefits:
|
- All claims
incurred outside your province of residence, must first be
submitted to your provincial Health Plan for reimbursement. Any
eligible unpaid balance may then be submitted to Manulife for payment under the Benefit Plan. The Plan will reimburse
eligible health care expenses incurred outside your province of
residence, but within Canada, at the same benefit level as
expenses incurred within your province of residence.
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| Out
of Country Benefits (Emergency Only): |
- Emergency Out of
Country expenses (limited to a 90 day absence):
Lifetime
maximum - $1,000,000 per person's lifetime
Annual
Reinstatement - $10,000 per individual
- Average
ward accommodation in Canada
- Benefit
terminates on March 31st following the Member’s 70th birthday
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