|
Schedule
of Benefits
Benefit
Level 04 (default)
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MEMBER LIFE
INSURANCE |
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|
All Eligible
Members |
Amount
of Insurance |
|
Under age 65 |
$ 100,000 |
|
Age 65 to age
69 |
$ 50,000 |
|
Age 70 and
over |
$
5,000 |
MEMBER
& FAMILY DENTAL BENEFIT
Co-Insurance
(paid by the Plan): 90%: of all eligible Basic & Restorative expenses
Maximum: Basic &
Restorative (combined) - no annual maximum
60%: of all eligible
Major expenses paid by the plan
50%: of all eligible
orthodontic expenses paid by the plan
Maximum: Basic,
Restorative & Major (combined) - $1,500 per individual per Plan Year
Orthodontic - $2,500
per lifetime per dependent child up to and including age 18.
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.
Your
dental benefits and those of your dependents will terminate when you
reach age 75.
MEMBER &
FAMILY HEALTH CARE BENEFIT
|
Co-Insurance
(paid by the plan): |
90%: 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.
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|
Age 75 or
over: |
- No Health
Care Benefits for you or your family.
|
| |
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HEALTH CARE
BENEFITS |
BENEFIT
MAXIMUMS |
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|
|
Prescription
Drugs:
|
- Manulife Financial: Pay Direct
Drug Card,
- drugs
available only by prescription, and with the following limits:
|
| |
a)
Maximums: |
- up to $7
dispensing fee per prescription or refill
- up to
generic drug expense unless the physician indicates "no
substitution" on the prescription.
|
| |
b)
Maintenance
Drugs: |
- 90 day
supply at one time, once classed as a maintenance drug (i.e. one
$7 dispensing fee per 90 days).
|
|
Vision Care: |
- Prescription
lenses (including contact lenses), frames, and the fitting of
glasses; up to $500 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.
|
| |
|
| HEALTH
CARE BENEFITS |
BENEFIT
MAXIMUMS |
| 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: |
- When
prescribed to a maximum of $450 per Plan Year
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| |
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Orthopaedic
Shoes: |
- When
prescribed and not attached to or forming part of a brace, to a
maximum of $300 per Plan Year
|
| |
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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.
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|
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: |
- Up to a
combined lifetime maximum of $5,000.
|
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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:
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- 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
|
| 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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