Health Plan Schedule of Benefits

Benefit

Reimbursement

Maximum Benefit

DRUG
Based on the Provincial Formulary with a generic rider

80%

$3,000 per benefit year

Supplemental Health Care

Physiotherapist
(physician’s prescription required)

80%

$20/visit to $300 per benefit year

Registered Massage Therapist
(physician’s prescription required)

80%

$20/visit to $300 per benefit year

Speech Language Pathologist
(physician’s prescription required)

80%

$20/visit to $300 per benefit year

Psychologist or Social Worker
(physician’s prescription required)

80%

$20/visit to $300 per benefit year

Chiropractor
(including one x-ray exam per benefit year)

80%

$20/visit to $300 per benefit year

Osteopath
(including one x-ray exam per benefit year)

80%

$20/visit to $300 per benefit year

Naturopath

80%

$20/visit to $300 per benefit year

Dental Accident
(pre-authorization required)

80%

Of eligible expenses and reasonable and customary charges. Services must be performed within 12 months of the accident. Limited to $1,000 per accident.

Ambulance

80%

Limited to $250 per occurrence

Orthopaedic Shoes
(pre-authorization & physician’s prescription required)

80%

$150 per benefit year, provided they are not solely for athletic use.

Trusses, Crutches, Splints & Braces

80%

Braces not solely for athletic use.

Artifical Limbs & Prosthetics

80%

Reasonable and customary charges.

Medical Equipment
(wheel chairs, hospital-type beds & traction kits)

80%

Tutorial
(after 15 days confinement due to injury or illness)

80%

$15/hour to $2,000 per benefit year

Out-of-Country Emergency Care & Global Medical Assistance

100%

$2,000,000 in a lifetime

Accidental Death & Dismemberment

NOTE: User fees associated with coverage provided by a provincial healthcare program are not covered by this plan.

The health plan would be at a cost of $89 per benefit year.

ANNUAL MAXIMUM

$750 per benefit year

Diagnostic & Preventive
(exam, diagnosis, x-rays, polishing & scaling)

80%

Limited to once per benefit year. Scaling up to 2 units & 1 unit of polishing.

Minor Restorative
(fillings, child space maintainers, denture repairs, relining, and rebasing)

70%

Extractions

50%

Limited to 2 wisdom teeth per benefit year

Endodontic
(root canals)

20%

Periodontal and Other Oral Surgery)

20%

Excluding additional scaling

Pre-approval required for treatment plan exceeding $500.

NOTE:  In the event of any discrepancy between the information herein and our contract with the insurer, the terms of the contract will apply.

The dental plan would be at a cost of $100 per benefit year.