Benefits summary for active employees
Updated March 2016
6
Snapshot of your benefits
8
Benefits phonebook
Administrative events
10
Getting PSGIP coverage13
Buying home and auto insurance13
Joining the PSGIP when your spouse’s coverage elsewhere ends14
Changing PSGIP coverage15
Making a claimEveryday events
16
Going to the doctor16
Visiting a paramedical professional17
Going to the pharmacy22
Getting an eye exam or glasses/contact lenses23
Buying medical equipment and supplies26
Visiting the dentistIllness or injury
28
Calling an ambulance29
Going to the hospital30
When you are a hospital outpatient30
When you need private nursing care31
Damaging your teeth in an accident32
If you suffer a serious accidental injury34
If you become disabledTravel events
36
Medical emergencies while outside your province of residence39
Getting a referral for treatment outside your home provincePersonal events
40
Becoming a parent40
Becoming legally separated or divorced41
When a child is no longer considered a dependent41
Having a new spouse42
If you take a leave of absence or are on a layoff43
If your employment ends44
If you retire46
If you pass away47
If your spouse or child passes away48
Your well-being ... and the plan’s, too!
Other things you should know
50
General exclusions53
When coverage ends56
Glossary
Appendices
59
A: Dental details70
B: Additional benefits for accidental injury or death77
C: Long-term disability detailsKaren Fraser
Chair, PSGIP Trustees
4
On behalf of the Trustees of the PEI Public Sector Group Insurance Plan (PSGIP), I am pleased to provide you
with this unique benefits guide.
Much like the plan itself, this guide helps you plan for life, for the various times in your life when you might need a helping hand
to cover health and dental expenses. The guide also describes other benefits that may be available to you.
In fact, the guide is like the plan itself … in more ways than one!
As you will see in this benefits guide, PSGIP stands for more than PEI Public Sector Group Insurance Plan. It also stands for these qualities and more. I invite you to read this guide and discover for yourself how the PSGIP helps you plan for life!
Helping
you
QUALITY COMPREHENSIVE CONVENIENT PROMOTES RESPONSIBILITYYour PSGIP ... Your guide ...
• is a good planthat provides sound financial protection in times of need.
• provides a wide range of benefitsfor both you and your family in times of illness or injury.
• offers a practical drug card with many advantages—no need to pay the total cost of a drug up-front, no claim form to complete, and more!
• is your plan … and your money!As a result, you have a direct impact on both cost increases and savings.
• is a good source of informationabout your benefits and what you need to do.
• provides key details on a wide range of events, from travelling outside PEI to just going to the pharmacy. • offers practical features,
including a snapshot of your benefits and a benefits phonebook. With this handy reference tool, finding information has never been easier!
• is a good source of useful tips to help keep both you and your plan healthy!
The plan’s mission:
Providing benefits
The Public Sector Group Insurance Plan (PSGIP) is designed and intended to provide group insurance benefits to plan beneficiaries as determined by the parties.
The Trustees’ mission:
Working for the good of the plan
The Trustees of the Public Sector Group Insurance Plan are mandated to act in the best interest of the plan and its beneficiaries.
To achieve this objective, the Trustees are committed to the following qualities:
Proactiveness Transparency Integrity
• Identify and analyse group insurance trends and best practices
• Make recommendations to optimize the plan’s cost-effectiveness and long-term sustainability
• Inform parties of all decisions • Educate beneficiaries on the
plan and their role
• Adhere to the Trust document at all times
• Respect all legal documents and requirements
H
EALTH COVERAGEFor a quick look:
Please note that this snapshot is only a summaryof your PSGIP benefits. It does not describe all the details, such as applicable maximums. Certain limitations and conditions apply.Please read your guide for details.
Health benefits
Dental benefits
Examples of eligible expenses
Disability benefits
Benefit equal to 70% of your monthly earnings, indexed annually, to a maximum of $6,000 per month.
Ambulance
Note: Additional benefits may be payable in the event of accidental injury. Please see page 32 for details.
• 100% of the first $50 of eligible expenses per person, per calendar year, and 80% of any excess
Drugs • 80% of the first $150 of eligible expenses per drug requiring a prescription, and 100% of any excess
• Based on the cost of the lowest-cost generic equivalent of the prescribed brand name drug, unless your doctor provides medical evidence that the prescribed drug cannot be substituted
Hospital • 100% of the difference between ward and semiprivate room
• 80% of the difference between semiprivate room and private room
Medical services/ equipment
• 80%
Paramedical services
• All paramedical services except massage therapy: 80%, subject to a maximum reimbursement of $800 in a calendar year as well as a certain number of visits, depending on the type of paramedical services
Vision care
• Massage therapy: 80% (subject to a maximum reimbursement of $240 per calendar year)
• Eye exams: 80%, once every 2 calendar years (every calendar year for persons under 18)
• Eyeglasses or contact lenses: 80%, subject to a maximum reimbursement of $160 every 2 calendar years (every calendar year for persons under 18)
Option 1 • 80% for basic services only
Option 2 • 80% for basic services
• 50% for major services (max. $1,000 per person per calendar year)
• 50% for orthodontics for you and your dependents (lifetime max. $3,000 per person)
B
ASIC SERVICES• Routine check-ups • Fillings
• Teeth polishing/cleaning • Root canal therapy
M
A JOR SERVICES • Dentures • Crowns • Bridges • Inlays/onlays6
Travel benefits
Coverage of up to $1 million per emergency above what your provincial plan pays.
Examples of eligible expenses and services
N
ATURAL DEATHA
CCIDENTAL DEATHYour death Basic coverage:
• Full-time employees: 3 x your annual earnings, to a maximum of $300,000 1
• Part-time Civil Service employees: 2 x your annual earnings; minimum $25,000 and maximum $175,000 • Permanent part-time CUPE employees: $40,000
• Permanent part-time UPSE employees, and excluded, non-union and non-excluded employees: $40,000
• Permanent part-time PEINU employees: $100,000 • Part-time UPSE employees covered before June 1, 1996:
2 x employment guarantee; minimum $25,000 and maximum $175,000
• Permanent part-time IUOE employees: $50,000 PLUS
Optional life insurance coverage of up to $300,000, in units of $10,000
Same amounts as for natural death PLUS
Basic accidental death coverage equal to your basic life insurance coverage PLUS
Optional accidental death coverage of up to $300,000, in units of $10,000
Spouse’s death
$4,000 2 PLUS
Optional life insurance coverage of up to $300,000, in units of $10,000
Same amounts as for natural death PLUS
Optional accidental death coverage equal to 50% of your optional accidental death coverage (60% if you have no dependent children)
Dependent child’s death
$3,500 PLUS
Optional life insurance coverage of $10,000
Same amounts as for natural death PLUS
Optional accidental death coverage equal to 15% of your optional accidental death
coverage if you have a spouse (20% otherwise; maximum $20,000 per child)
1 If you are a full-time Civil Service employee and you did not elect a benefit of 3 x your annual earnings on December 1, 1996: 2 x your annual earnings, to a maximum of $175,000. If you are a full-time UPSE employee who did not elect coverage of 3 x annual earnings during June 1996, or a part-time UPSE employee who was covered before June 1, 1996: 2 x employment guarantee; minimum $25,000 and maximum $175,000.
2 $3,500 if you are a permanent, full-time UPSE employee who transferred from the Civil Service to the Health Sector on August 1, 1995,
• Hospitalization • Physician services • Referrals
• Return home airfare • Return of vehicle
• Living expenses for travelling companion
• Arrangements for direct payment for physicians’ services, hospitalization, and other insured services
R
EIMBURSEMENT AT THE SAME LEVEL AS INC
ANADA• Prescription drugs • Wheelchairs • Crutches
• Other eligible expenses under the plan’s health coverage
Death benefits
R
EIMBURSEMENT AT100%
Trustees
The PSGIP Trustees are a group of member representatives consisting of:
The PSGIP Trustees work diligently to ensure that the plan runs smoothly. They act solely in the best interest of the plan and its beneficiaries, in line with their mission statement (see page 5) and the Trust Document.
Their activities include:
The Trustees cannot make plan changes that result in material rate increases or add new benefits to the plan on a cost-shared basis. Also, to increase or enhance benefits, the Trustees require unanimous approval or direction from the parties.
Your key contacts:
CUPE: Wanda Livingstone
IUOE: Valerie Robinson
Department of Health: Kellie Hawes, Heather Larkin and Rick Adams
Province of PEI: Pamela MacEachern and
Karen Fraser, Chair
PEINU: Jennifer Doyle
UPSE (Civil Service): Kirk Morrison
UPSE (Health): Craig MacKenzie, Vice Chair
• establishing and administering the fund; • entering into all necessary contracts; • establishing and administering reserve
funds;
• appointing and monitoring the performance of the administrator, consultants, insurance carriers, etc.;
• investing funds and paying expenses;
• communicating regularly and openly with plan members and parties;
• reviewing requests from parties for additional expanded services;
• making plan changes, where allowed; and • increasing rates resulting from plan experience.
F
OR COMMENTS ABOUT THEPSGIP
AND ITS BENEFITSPublic Sector
Group Insurance Plan
1 Harbourside, Brecken Building Charlottetown, Prince Edward Island C1A 8R4
Johnson Incorporated
Johnson is your benefits resource and the plan administrator of all your benefits. This means they: • answer questions;
• keep records;
• determine eligibility for coverage; and
• make sure you receive all necessary documents. They handle claims for disability, accident and death benefits as well as claims under the Preferred Services Home-Auto Plan.
When you call, be sure to specify the applicable policy number:
• Basic Life, Dependent Life & Disability: 165211 • Optional Life: 159864
• Accident: ABT102324(basic coverage), OKE102324(optional coverage)
Although Johnson is the plan administrator, Great-West Life insures benefits in the event of disability or natural death, and ACE INA Insurance insures benefits in the event of a serious accidental injury or accidental death.
Great-West Life
Great-West Life handles health and dental claims. When you call, be sure to specify the policy
number:56530.
Travel Assistance provider
The Travel Assistance provider handles all travel-related claims.
When you call, be sure to specify the policy number:335336.
J
OHNSONI
NCORPORATED:
F
OR QUESTIONS ABOUT COVERAGE,
TO MAKE CHANGES,
OR TO CLAIM DISABILITY,
ACCIDENT AND DEATH BENEFITSCharlottetown area: (902) 628-3537
Elsewhere: Toll free1 800 371-9516
You can also visit (for inquiries other than for claim reimbursements) or write to: 201 Buchanan Drive
(Buchanan Plaza) Charlottetown, PEI C1E 2E4
G
REAT-W
ESTL
IFE: F
OR QUESTIONS ABOUT HEALTH AND DENTAL CLAIMSToll free: 1 800 957-9777
To obtain a claim form, you can also click on www.greatwestlife.com
T
O PICK UP OR SUBMIT A CLAIM FORM47C Beach Grove Road Charlottetown, PEI C1E 1K5
Business hours: 8:30 a.m. - 5:00 p.m. Monday to Friday
T
RAVEL ASSISTANCE:
I
N THE EVENT OF AN EMERGENCYToll free: 1 866 530-6024, from Canada or the United States
Collect: (905) 816-1901
F
OR GENERAL INQUIRIES REGARDING CLAIM OR COVERAGEToll free: 1 800 957-9777
T
O SUBMIT A CLAIM FORMAssistance Centre - Claims Department P.O. Box 97, Station A
Mississauga, Ontario L5A 2Y9
Getting PSGIP coverage
To participate in the PSGIP, you must reside in Canada and be a Civil Service or Health PEI employee, as described below:
C
IVILS
ERVICEH
EALTHPEI
You are part of Health PEI if you belong to any of the following groups:
You may join the PSGIP if you are:
Taking care of business:
Class 1 • Permanent full-time employees
• Permanent part-time employees (including provisional and probationary employees) with a guarantee of at least 40% of the normal working hours for at least 6 months
• Contract employees for whom benefit eligibility is specified in the employment contract
Class 2 • Permanent part-time employees (including provisional and probationary employees) with a guarantee of less than 40% of the normal working hours
Class 3 • Permanent part-time employees with a guarantee of at least 37.5 hours per week, for a minimum of 600 hours and a maximum of 6 months during the year
Class 4 • Temporary employees after 6 months of continuous employment
10
• Prince Edward Island Nurses Union (PEINU) • International Union of Operating Engineers (IUOE) • Canadian Union of Public Employees (CUPE)
• Prince Edward Island Union of Public Sector Employees (UPSE)
• Excluded Employees
• Non-Union, Non-Excluded Employees • a permanent full-time employee working at least 30 hours per week;
• a permanent part-time employee working less than the fully prescribed hours of work on a recurring and regularly scheduled basis;
• a temporary UPSE, IUOE or excluded employee hired for 12 months or more.
Note: If you are a casual UPSE employee and you had coverage before August 1, 1995, you may continue your coverage in effect on August 1, 1995. However, you are not eligible for any additional benefits.
W
HEN COVERAGE BEGINSAll coverage (except optional life and accident insurance)1will normally begin as soon as you are
eligible, provided you enrol within 31 days (within 90 days for health and dental coverage) following the applicable eligibility date listed below.
Civil Service—Class 1 • All coverage • Your first day of employment 2 Civil Service—Class 2 • Health, dental and travel coverage • Your first day of employment
• Optional life and accident insurance • After 6 months of continuous employment 2
Civil Service—Class 3 • All coverage, except for long-term disability
• Your first day of employment 2
Civil Service—Class 4
• Health, dental and travel coverage • After 6 months of continuous employment • Basic and optional life and accident
insurance, and long-term disability coverage
• After 12 months of continuous employment 2
Note: You are not eligible for basic life and accident insurance or long-term disability coverage.
Note: You are not eligible for basic life and accident insurance or long-term disability coverage.
Note: You are not eligible for long-term disability coverage.
E
MPLOYMENT CATEGORYC
OVERAGEE
LIGIBILITY DATETemporary employees working at least 40% of the normal weekly working hours
• Health, dental and travel coverage as well as optional life and accident insurance
• After 6 months of continuous employment 2 Temporary employees working less
than 40% of the normal weekly working hours
• All coverage • First day of the month following 1 month of continuous employment 2
Health PEI
Note: If you are a casual employee and you have a break in service, you must fulfill a new waiting period.
1 No eligible individual may be covered more than once under the optional accident insurance policy. If you are covered as an employee or retiree, you cannot be covered as a spouse or dependent child of another employee or retiree. In addition, only one spouse can choose coverage for dependent children. Furthermore, your spouse and eligible children can only be insured if you are covered under the plan.
2 If you apply for any optional life insurance within 31 days following your eligibility date, a portion of the coverage (up to $30,000 for yourself, up to $30,000 for your spouse, and $10,000 for each child) will come into effect on the first of the month after Johnson receives your application. The difference, if any, will take effect once the insurer approves your proof of good health.
If you apply for any optional accident insurance, coverage will come into effect on the first of the month after Johnson receives your application.
1. To join the PSGIP, you must obtain an enrolment form from Johnson.
2. Complete the form.
3. Gather any supporting documents that may be required.
• If you choose family coverage, you must provide confirmation of your child’s continuing attendance at an accredited college or university each year for continued coverage.
• If your child is handicapped, you must provide satisfactory proof that he or she is incapable of self-support because of the handicap.
• If you enrol within 31 days after your eligibility date, you must submit proof of good health if you wish to purchase over $30,000 of optional life insurance for yourself or your spouse.*
• If you enrol in the PSGIP for health and dental coverage over 90 days after your eligibility date, you must provide proof of good health for health coverage. If you must provide proof of good health, ask Johnson for a medical questionnaire. Depending on your responses, you may be required to undergo a medical examination.
4. Return the form and any
supporting documents to Johnson.
* If you wish to purchase optional life insurance for yourself or your spouse after 31 days, you must submit proof of good health.
What happens if I don’t enrol
within 31 days (within 90 days
for health and dental coverage)
following my eligibility date?
If you enrol after the 31-day deadline (after 90 days for health and dental coverage), two things will happen: 1. You will be required to submitproof of good health for all persons you wish to enrol, including
yourself, for optional life and health coverage. This does not apply if you already enrolled and you later have a "new" dependent (e.g., you have a child or get married).
When proof of good health is required, coverage will begin on the date the insurer approves the proof of good health, provided you are actively at work on that day. 2. Dental benefits will be limited to
$100 during the first 12 months of coverage. After 12 months, the normal reimbursements
applicable under the plan will apply. This provision does not apply if you damage your teeth in an accident.
What happens if I’m not at
work when my coverage is to
begin?
Coverage will start when you return to active work for full pay.
Buying home and
auto insurance
You can also enrol in the Preferred Services Home-Auto Plan offered by Johnson, provided you meet certain eligibility requirements. For details, please refer to “Appendix D: Home and auto insurance.”
Contact Johnson or visit www.johnson.cafor more information. You can call them toll-free at
1 800 563-0677.
Joining the PSGIP when your
spouse’s coverage elsewhere ends
If you do not choose PSGIP’s health, dental or travel coverage because you are covered under your spouse’s plan, you may join the PSGIP if your spouse’s coverage ends. You have 31 days following the end of your spouse’s coverage to enrol without having to provide proof of good health.
Changing PSGIP coverage
You may change the following types of coverage under the plan:
1. If you wish to change coverage, contact Johnson.
2. You may be asked to submit proof of good health, depending on the coverage you wish to change.
Event When coverage begins
Newborn
You are applying to cover dependents more than 31 days after first acquiring a dependent
On the date the insurer approves the proof of good health
You are applying for increased life or accident insurance On the date the insurer approves the proof of good health
At birth or the date coverage would otherwise begin, whichever is later
14
Health coverage In the event of a change in your family status, you may also change from single to family coverage, and vice versa, or add new dependents. Proof of good health may be required.
Dental coverage If you choose option 1 (basic services only), you can change to option 2 (basic and major services) anytime. Once you choose option 2, you cannot select option 1 afterward.
In the event of a change in your family status, you may also change from single to family coverage, and vice versa, or add new dependents.
Travel coverage In the event of a change in your family status, you may change from single to family coverage, and vice versa.
Optional life insurance
You may change your level of coverage (for yourself and for your dependents) anytime. You must provide proof of good health if you wish to increase your coverage.
Optional accident insurance
How do I make a health or
dental claim if I also have
coverage under my spouse’s
plan?
If you and your spouse both have family coverage, you may submit your claims to both plans and get reimbursed for 100% of your covered expenses.
The steps to follow will depend on who incurred the expenses: • Your expenses: The PSGIP is the
first payer.
• Your spouse’s expenses: Your spouse’s plan is the first payer. • Your children’s expenses: Submit
a claim to the plan of the parent whose birthday falls first in the calendar year. For example, if your birthday is March 11 and your spouse’s birthday is July 8, submit claims for your children’s expenses to the PSGIP first, and then to your spouse’s plan. Be sure to keep copies of your receipts.
Special note about your drug card
If you and your spouse both have family coverage and your spouse has a drug card under his or her plan, the pharmacist can use your PSGIP drug card to electronically process claims under both your plan and your spouse’s plan, right on the spot!
Making a health or dental claim
The steps for making a claim will depend on the eligible expense you are claiming. For example, you can use your drug card for eligible drug expenses. For most other expenses, you generally need to submit a claim form to Great-West Life.
Please refer to the relevant event in this booklet for specific instructions.
If you have a question about a health or dental claim, contact Great-West Life at their special toll-free number: 1 800 957-9777.
For other types of claims, please refer to page 9 for the applicable contact and telephone number.
D
EADLINE TO SUBMIT CLAIMSYou should submit your claim form and receipt within 12 months after incurring the expense. Failure to provide a receipt will not invalidate nor reduce any claim if it is not reasonably possible to furnish the receipt within a 12-month period, provided it is provided within 24 months.
Are you looking for a fast and convenient way to receive your health or dental reimbursement? You can have Great-West Life deposit your claim reimbursements directly in your bank account.
1. Call or write to Great-West Life, and ask for a direct deposit.
2. Give Great-West Life your banking information: • a voided cheque, if you are writing; or
• account information, in writing.
The initial set-up takes one to two weeks. Afterward, deposits should take only one to two days.
Get into the habit:
Going to the doctor
Your provincial health care plan covers the cost of seeing a doctor. Simply show your Medicare card when you visit your doctor.
Visiting a paramedical professional
The plan covers the usual cost of eligible paramedical services as follows:
1. Pay the total cost up-front and ask for a receipt.
2. Complete a claim form.
3. Send the claim form and your receipt to Great-West Life within 12 months after incurring the expense.
You pay PSGIP
pays 80%
20%
•All paramedical services except massage therapy: up to 20 visits per type of practitioner (6 visits for social workers) per calendar year, to a maximum
reimbursement of $800 per calendar year for all practitioners combined
•Massage therapy on or after September 1, 2005: Maximum reimbursement of $240 per calendar year
Important:
Reimbursement of paramedical services is based on the usual charge for each service, up to the maximum charge set in theSchedule of Fees for the practitioner providing the service. If there is no
Schedule of Fees, Great-West Life will set a fee for the service.
Who is considered a
paramedical professional?
• Acupuncturists • Chiropodists or podiatrists • Chiropractors • Clinical psychologists• Massage therapists (covered as of September 1, 2005) • Naturopaths (covered as of January 1, 2009) • Osteopaths • Registered physiotherapists • Social workers
• Speech therapists (covered as of January 1, 2009)
The paramedical practitioner must be registered in the province where the service is given. The person cannot be a member of your
immediate family or someone who lives with you.
A visit to a social worker is covered if you have a written referral from the Prince Edward Island Government Employee Assistance Program. Before using the services of a massage therapist, you must have authorization from a physician and the massage therapist must be registered with the Massage Therapy Association.
Does the PSGIP also cover the
cost of any laboratory tests or
X-rays?
Yes, provided a licensed chiropractor, osteopath, chiropodist or podiatrist recommends the tests or X-rays.
Going to the pharmacy
The plan covers the usual cost of drugs that require a prescription. Coverage is based on the cost of the lowest-cost generic equivalent of the prescribed brand name drug, unless your doctor provides medical evidence that the prescribed drug cannot be substituted.
You will not pay more than $30 per eligible drug appearing on your prescription if you select the lowest-cost generic drug or a brand name drug without a generic equivalent.
You can select a brand name drug that has a generic equivalent but you may pay more if there is no medical reason against having a generic substitution.
You pay PSGIP
pays PSGIPpays
For the first $150 of eligible expenses per prescription drug For additional eligible expenses per prescription drug 80% 100% 20%
18
What is a generic drug?
A generic drug is a reproduction of a brand name drug. Companies that research and develop brand name drugs hold a patent on the formula. The patent gives the drug maker the exclusive right to produce and sell the drug.
At the time of filing for a patent, a drug has two names -- a generic name that is the drug's common scientific name and a brand name for the marketplace. For example, "ibuprofen" is a generic name of the brand name drug "Advil."
When the patent on the brand name drug expires, the generic version of the drug becomes available. Since the research has already been paid for, a generic drug can cost a lot less than the brand name drug. Health Canada applies the same standards and tests to generic drugs so that they are as effective and safe.
Example
Lowest-cost generic drug = $50
Plan pays $40 (80% of $50)
You pay $10 (20% of $50, up to $30/prescription drug)
What if there is a medical
reason why the lowest-cost
generic equivalent doesn’t
work for me?
If there is a medical reason why you cannot take the generic equivalent of the brand name drug, you can still request that the brand name drug be covered by the plan. You and your doctor must complete Great-West Life’s Request for Brand Name Drug Coverage form. You can get a form by calling Great-West Life or by downloading the form from the Great-West Life website at www.greatwestlife.com under Client Services ►Group Benefits Plan Members ►Forms for Group Benefits Plan Members ► Other Forms.
Send the completed form to Great-West Life at the address indicated on the form. Great-West Life will assess your request and send you a letter letting you know if the request for brand name drug coverage is approved.
In addition to competitive coverage, the PSGIP provides you with a pay-direct drug card. This card offers a number of attractive features:
• Simple and convenient
• Pay for only your share of the cost • No need to wait for any reimbursement • No claim forms to complete
• Accepted at most drugstores in Canada
You may use the card for prescription drugs, diabetic supplies, and certain over-the-counter, life-supporting drugs that have been prescribed for you and approved for reimbursement by Great-West Life.
You may not use the card, however, for items such as:
Also see “General exclusions” starting on page 50.
Your drug card:
Practical and easy to use
Who can prescribe drugs?
• Physicians• Dentists
• Nurse practitioners
• Pharmacists where allowed by law
Does the PSGIP cover vaccines?
The plan will cover preventative immunization vaccines and toxoids, subject to a lifetime maximum reimbursement of $500 per person.I’m trying to stop smoking.
Can the plan help?
Yes. The plan covers 50% of the usual cost of nicotine replacement
products, subject to a lifetime maximum reimbursement of $300 per person.
Does the PSGIP cover Viagra?
Yes. It pays for the usual cost of Viagra and other similar medications, to an annual maximum of $250.• Alcohol • Bandages
• Blood glucose monitors, dextrometers
• Contraceptives other than contraceptive drugs and products containing a contraceptive drug • Cosmetic items • Cotton • Disinfectants • Fertility drugs
• Food substitutes, infant food or formula
• Hair growth stimulants • Homeopathic medicines • Products that can be bought
without a prescription, unless the policyholder approves them • Non-disposable insulin injectors • Spring-loaded devices used to
hold lancets • Sunscreens
• Vitamins (except injectible), minerals, dietary supplements
Does the PSGIP cover
experimental or
non-prescription drugs?
The plan does not cover experimental drugs. Eligible drugs must be approved by the Canadian government for sale to the general public and have a Drug Identification Number (DIN).However, the plan may cover the usual cost of certain
life-supporting, non-prescription drugs approved by Great-West Life.
Does the plan cover an
unlimited supply of
therapeutic or maintenance
drugs?
The plan covers a supply of up to 100 days at a time. You need to get refills for excess amounts. When using your drug card
1. Give your card to the pharmacist.
2. The pharmacist will enter the data on your card and your prescription into his or her computer system.
3. Within seconds, this data is electronically processed, and the computer system will indicate your portion of the cost.
4. You pay for only your portion of the cost.
5. Do not submit a claim form to Great-West Life. Your claim is submitted automatically through the computer system.
6. If you also have coverage under your spouse’s plan, you may use your drug card for that plan, too! Please see the Q&A section on page 15 for details.
When you do not have your drug card or when the card does not work
1. Pay the total cost up-front and ask for a receipt.
2. Complete a claim form.
3. Send the claim form and your receipt to Great-West Life within 12 months after incurring the expense. The receipt must show the prescription number and the name of the drug or the Drug Identification Number (DIN).
When it comes to prescription drugs, here’s one pill that’s easy to swallow: it may be possible to obtain the same health care results for less. In fact, there are various ways you can cut your costs without cutting down on your care.
Want to know more? Read all about it in the section “Your well-being ... and the plan’s, too!” on page 48.
Getting an eye exam or glasses/contact lenses
The plan covers the usual cost of eligible vision care as follows:
E
LIGIBLE EXPENSES Eye exams (including eye refractions)• For persons over age 18: once every 2 calendar years • For persons age 18 and under: once every calendar year A registered, licensed optometrist or ophthalmologist must perform the eye exam.
Contact lenses or eyeglasses Contact lenses for certain conditions
1. Pay the total cost up-front and ask for a receipt.
2. Complete a claim form.
3. Send the claim form and your receipt to Great-West Life within 12 months after incurring the expense.
Does the plan cover
sunglasses or safety glasses?
Yes, provided an ophthalmologist or optometrist prescribes them to correct vision. Coverage is the same as for regular prescription glasses.You pay PSGIP
pays 80%
20%
Certain maximums apply, as described below.
22
• Eyeglasses or contact lenses: 80%, subject to a maximum reimbursement of $160 every 2 calendar years (every calendar year for persons under 18)
An ophthalmologist or optometrist must prescribe the contact lenses or eyeglasses to correct vision.
• If you suffer from ulcerated keratitis, severe corneal scarring, keratoconus (conical cornea) or aphakia: reimbursed up to $160 in any period of 2 consecutive calendar years
A licensed ophthalmologist must prescribe the contact lenses. The plan will pay for these contact lenses only if your sight can be improved to at least the 20/40 level by contact lenses, but it cannot be improved to that level with eyeglasses.
Buying medical equipment and supplies
The plan covers the usual cost of eligible medical equipment and supplies as follows, provided a physician has prescribed them:
Certain maximums apply, as described below.
You pay PSGIP
pays 80%
20%
E
LIGIBLE EXPENSESS
PECIAL NOTESApnea monitor Covered if approved by Great-West Life
Artificial limbs/eyes and other prosthetic devices
Covered if non-myoelectric and approved by Great-West Life Important notes:
• Talk to Great-West Life before making your purchase, as the cost varies greatly. Great-West Life will let you know how much the plan will pay based on the least expensive device that is medically adequate.
• Replacements are covered if they are due to a pathological change.
• The plan pays for repairs and/or adjustments up to $40 in any calendar year, including the cost of repairs and/or adjustments to walkers and braces.
Asthma nebulizer Covered if approved by Great-West Life
Casts Covered if approved by Great-West Life Breast prosthesis after
mastectomy
Including replacement(s) every 2 calendar years
Breathing appliances Reimbursed up to $240 every 5 consecutive calendar years
Examples of breathing appliances: respirators, compressors, and inhalers (including Maxi-Mist, Medi-Maxi-Mist, Shucho Maxi-Mist, and Pulmo Aids)
24
E
LIGIBLE EXPENSESS
PECIAL NOTES Certain diagnostic tests, radiumtreatments, and X-rays
Compressors Covered if approved by Great-West Life
Crutches and canes
Diabetic supplies
Hearing aids and repairs
Reimbursed up to $900 per ear every 5 consecutive calendar years Batteries are not covered
Medical equipment and supplies not covered by the plan
The plan does not cover the following items or any other item not listed as an eligible expense, even when prescribed by a physician:
Also see “General exclusions” starting on page 50.
• Air conditioners or purifiers • Blood pressure kits • Breast pumps
• Cataract contact lenses
• Craftmatic, Ultramatic, or other lifestyle beds
• Exercise equipment, machines, or programs
• Grab bars • Holter monitor
• Home or car modifications (for example, ramps or lifts)
• Hoyer lift • Humidifiers
• Mattresses, except for standard mattresses
with approved hospital beds • Obus formes or orthopaedic pillows • Raised toilet seats
• TENS units • Trapeze • Transfer bench
24
Hospital beds Reimbursement based on:
• the cost of rental or purchase, whichever is more economical; • Great-West Life’s approval before the purchase is made; and • the least expensive device that is medically adequate Spare parts or alternative supplies are not covered
Custom-made foot orthotics
Eligible expenses must be:
• prescribed by a physician, podiatrist, or chiropodist as being necessary after a biomechanical examination; and
• required for regular daily living activities, and not just for sports or recreation Expenses are reimbursed up to $240 per calendar year (including custom-made orthopedic shoes and any modifications)
Custom-made orthopedic shoes, including
modifications
Eligible expenses are covered if:
• prescribed by a physician, podiatrist, or chiropodist; and
• no other method such as orthotics and/or off-the-shelf orthopedic shoes can correct the problem Expenses are reimbursed up to $240 per calendar year (including custom-made foot orthotics) You can use your drug card to cover these expenses!
Examples of diabetic supplies: disposable needles, syringes, lancets and testing materials for monitoring diabetes
E
LIGIBLE EXPENSESS
PECIAL NOTESWalkers and braces Covered if approved by Great-West Life Important notes:
• Talk to Great-West Life before making your purchase, as the cost varies greatly. Great-West Life will let you know how much the plan will pay based on the least expensive device that is medically adequate.
• Replacements are covered if they are due to a pathological change.
• The plan pays for repairs and/or adjustments up to $40 in any calendar year, including the cost of repairs and/or adjustments to standard non-myoelectric artificial limbs/eyes and other approved prosthetic devices.
Wheelchairs (standard manual or electric)
Reimbursement based on:
• the cost of rental or purchase, whichever is more economical; • Great-West Life’s approval before the purchase is made; and • the least expensive device that is medically adequate Spare parts or alternative supplies are not covered.
Insulin pumps
Ostomy supplies Covered if approved by Great-West Life
Covered once every 5 years, to a maximum reimbursement of $5,200
Oxygen
Oxygen equipment Covered if approved by Great-West Life
Stump socks
Surgical stockings Up to 2 pairs each calendar year
Temporary therapeutic equipment
Reimbursement based on:
• the cost of rental or purchase, whichever is more economical; • Great-West Life’s approval before the purchase is made; and • the least expensive device that is medically adequate Spare parts or alternative supplies are not covered.
1. Where applicable, before you incur an expense, ask Great-West Life to approve the expense.
2. Pay the total cost up-front and ask for a receipt.
3. Complete a claim form.
4. Send the claim form and your receipt to Great-West Life within 12 months after incurring the expense.
Note:For diabetic supplies, you can simply use your drug card.
Surgical bras
The plan has two dental options: basic care and basic/major care. The plan will pay the usual cost of eligible dental expenses,
depending on your option and your reason for visiting the dentist. Eligible dental expenses are reimbursed based on the Dental
Association Suggested Schedule of Fees for General Practitioners or the Dental Specialist Fee Guide, if applicable.
Certain limitations and conditions apply.
Visiting the dentist
Are you going to the dentist for …
You pay PSGIP pays 80% 20% You pay PSGIP pays 50% 50%
Major restoration/dental problems (including orthodontics)? Basic care, such as a routine
check-up, fillings, other preventive care, or maintenance work?
Maximum reimbursement:
$1,000 per person each calendar year ($3,000/lifetime per person for orthodontic expenses, provided you chose the basic/major care option
1. Ask your dentist if he or she can bill Great-West Life directly.
2. If your dentist bills Great-West Life directly:
• Pay only your portion of the cost. You have no claim form to submit. If your dentist does NOTbill Great-West Life directly:
• Pay the total cost up-front and ask for a receipt. • Complete a claim form.
• Send the claim form and your receipt to Great-West Life within 12 months after incurring the expense.
3. For orthodontic treatments, obtain a treatment plan from your dentist and submit it to Great-West Life. The plan will pay 50% of the eligible expense up to the maximum, as follows: 30% of the cost at the beginning of the treatment, excluding the diagnostic fee, and the rest on a monthly or quarterly basis depending on how the dentist bills for the services or how you submit receipts. No advance payments will be made.
Also see “General exclusions” starting on page 50.
If your dental treatment will cost more than $500, Great-West Life recommends that you contact them before you incur the expense, to determine how much the plan will pay and how much you will pay. Here’s what you need to do:
1. For pre-determination of benefits, send Great-West Life a detailed description of the treatment plan and its cost.
2. You may also be asked to supply a fully completed written estimate plus pre-operative X-rays, diagnostic casts, and laboratory reports.
• Adjusting a bite problem
• Anaesthesia during dental surgery • Examinations
• Fillings (including white fillings) • Fluoride
• Getting a tooth pulled out
• Removal of a thin slice of a tooth to make more room for the teeth that are slightly crowded (interproximal discing) • Mouth guards during contact sports • Polishing of an existing filling
• Polishing or cleaning of teeth • Recall scaling
• Recontouring of teeth (for functional purposes only)
• Space maintainers
• Tests and other diagnostic services • X-rays
P
REVENTIVE CARE• Appliances (including adjustments) • Maintenance of existing dentures,
crowns, inlays, onlays, and bridgework • Major oral surgery
• Root canal therapy and other treatments of roots
• Treatment of gingivitis and other gum disease
M
AINTENANCE WORK • Dentures • Crowns • Bridges • Inlays • Onlays • VeneersM
A JOR RESTORATIONOverview of eligible expenses … in simple terms
Below is a simple summary of the types of expenses covered. If you need to know more, please refer to “Appendix A: Dental details” on page 59, where you will find: • a complete list of all the eligible expenses;
• a definition of each technical term, where needed; and • details on specific limitations and conditions.
• Procedures to correct crooked or misaligned teeth
Get well soon:
Calling an ambulance
If you are in an accident or become critically ill, the plan will cover the usual cost of a licensed
ambulance or other emergency service to transport you to the nearest hospital that is able to give the necessary emergency treatment. This also covers travel between hospitals.
Does the plan cover
the cost of someone to
accompany me?
If a licensed ambulance does not provide transportation, the plan may cover the cost of a person to accompany you, if it is medically necessary.
Does the plan cover the cost
of a registered nurse to
accompany me?
Yes, the plan will also pay up to $240 in any calendar year for the travel expenses of an
accompanying registered nurse, when medically necessary and approved by the plan. The nurse cannot be a relative. You pay PSGIP pays PSGIP pays 80% 20% 100%
For the first $50 of eligible expenses per person,
per calendar year
For additional eligible expenses
28
1. Pay the total cost up-front and ask for a receipt.
2. Complete a claim form.
3. Send the claim form and your receipt to Great-West Life within 12 months after incurring the expense.
A semiprivate room and a private room
What if I simply want to be in a
ward?
Once you get to the hospital, simply specify which type of room you would like to have.
If you ask to be put in a ward rather than a semiprivate room, you will have nothing to pay … even if they finally put you in a semiprivate room because there are no more beds in the ward!
What happens if my medical
condition requires that I have a
private room?
In that case, the provincial plan will cover the cost at 100%.
You pay PSGIP pays PSGIP pays 80% 20% 100% PSGIP pays 100% A ward and a semiprivate room The difference in cost
between …
Going to the hospital
The plan covers the usual cost of hospital accommodation in Canada as follows:
In addition to hospital accommodation, the plan covers the usual cost of medically necessary ancillary hospital services as follows, if you are admitted as an inpatient to a general hospital in another province and a government health plan does not fully cover
the cost. Ancillary hospital services include items such as drugs or recovery room expenses that were not
picked up by the provincial plan.
Maximum reimbursement: $1,000 per hospital admission
1. You have no claim form to complete. Simply provide the plan’s policy number and your certificate number, which you can obtain from your drug card or from Johnson.
2. The hospital will invoice Great-West Life directly.
3. If you have chosen a private room, the hospital will bill you directly for the portion of your expenses not covered by the plan.
When you are a hospital outpatient
If you need outpatient services and supplies from a hospital or a surgical supply company, the plan pays the usual cost of such things, as indicated on the right:
When you need private nursing care
If your doctor prescribes private nursing care at your home or in the hospital, the plan will provide the usual cost of such care, as follows:
1. Pay the total cost up-front and ask for a receipt.
2. Complete a claim form.
3. Send the claim form and your receipt to Great-West Life within 12 months after incurring the expense.
You pay PSGIP pays 80% 20% Maximum reimbursement: $8,000 per covered person each calendar year
1. Obtain written confirmation from your doctor that the service is medically necessary.
2. Obtain approval from Great-West Life prior to receiving any private nursing care.
3. Once you are receiving nursing care, you must obtain a claim form from Great-West Life specifically for this purpose.
4. Complete the claim form and submit it to Great-West Life within 12 months after incurring the expense.
• your doctor has determined, in writing, that it is medically necessary;
• Great-West Life has approved the service beforehand; • nursing care is provided within Canada by a registered nurse,
registered nursing assistant, or registered practical nurse; • the person providing nursing care does not normally live
with you or is not a member of your immediate family;
• if nursing care is provided in a hospital, the person is not an employee of the hospital;
• the nursing care professional provides skilled care that only he or she can provide; and
• the nursing care is not provided in a nursing home, rest home, home for the aged, or any facility that provides similar care.
Private nursing care
will be reimbursed providedALLof the following conditions are met:PSGIP pays 100%
Damaging your teeth in an accident
If your healthy, natural teeth are damaged or lost due to a sudden impact, the plan covers the usual cost of repairing or replacing the teeth, as follows:
To be reimbursed, you must complete treatment within 12 months of the impact unless treatment has to be postponed because of your age.
You pay PSGIP
pays 80%
20%
1. Submit a treatment plan within 180 days of the impact for treatments scheduled to occur more than 180 days following the impact. Please refer to page 27 for details on treatment plans.
2. Pay the total cost up-front and ask for a receipt.
3. Complete a claim form. Indicate on the form that the expense is the result of an accident. Great-West Life will require details of the accident and possibly X-rays.
4. Send the claim form and your receipt to Great-West Life within 12 months after incurring the expense.
Reimbursement will be based on the least expensive treatment that is adequate to correct the damage and on the current dental fee guide. No implants, treatments related to implants, or treatments to correct
Is my family covered?
Yes, provided you have purchased optional accidental death
coverage for both you and your dependents. Coverage is as follows:
• Your spouse’s coverage: 50% of your coverage (60% if you have no dependent children)
• Your dependent child’s
coverage: 15% of your coverage if you have a spouse
(otherwise, 20% up to $20,000 per child)
For example, let’s assume that you have optional accidental death coverage of $100,000 for yourself. If your spouse were to lose an arm, you would receive 75% of your optional coverage, as follows: Had you lost your arm
• 75% x $100,000 = $75,000 If your spouse were to lose an arm
• If you have dependent children: 50% x $75,000 = $37,500 • If you do not have dependent
children:
60% x $75,000 = $45,000
If you suffer a serious accidental injury
If you suffer a serious accidental injury that results in a covered loss within one year of the accident, the plan pays lump-sum benefits, as follows:
C
OVERED LOSS• Use of one leg or one arm
P
ERCENTAGE PAYABLE 200%75% • Use of one hand or one foot
• Entire sight in one eye • Speech or hearing in both ears • Hearing in one ear
• Thumb and index finger of the same hand • Four fingers of the same hand
662/ 3%
50% 331/
3%
• All toes of one foot 25%
32
1 Please note that basic life and accident insurance is not available if you are a Civil Service— Class 2 employee or a Civil Service—Class 4 casual employee working less than 40% of the normal weekly working hours.
2 Irreversible unconsciousness with total loss of brain function and complete absence of electrical activity of the brain, even though the heart is still beating.
The percentage payable varies according to the severity of the loss, as follows:
A percentage of your basic accidental death coverage (which is equal to your basic life insurance coverage
described on page 46)1
PLUS
A percentage of your optional accidental death coverage of up to $300,000, in units of $10,000
• Hemiplegia (paralysis of one arm and one leg on the same side of the body) • Paraplegia (paralysis of both lower limbs) • Quadriplegia (paralysis of all four limbs) • Use of both hands, both feet, or both arms • Entire sight in both eyes
• One hand and one foot
• One hand or foot and entire sight in one eye • Speech and hearing in both ears
• Brain death2
What happens if the accident
leads to death?
Should you die accidentally within one year of the accident, your beneficiary or estate will receive a lump sum.
Accidental death benefits are payable in addition to any other death benefits payable under your PSGIP coverage. Please see page 7 for details.
What happens if I am
unavoidably exposed to the
elements because of an
accident and suffer a covered
loss?
The plan will pay benefits for the loss, according to the table of losses on page 32.
What if I have more than one
covered loss from an accident?
The amount payable cannot exceed the highest covered loss. Forexample, if you had one loss payable at 50% of your coverage and another loss payable at 100% of your
coverage, the plan would pay 100% of your coverage.
For benefits to be payable, the loss of use must: • be total and irrecoverable;
• continue for 12 consecutive months; and • be determined by the insurer to be permanent.
Example of how this coverage works
For example, let’s assume that you have basic accidental death coverage of $90,000 and optional accidental death coverage of $100,000. If you were to lose an arm, you would receive 75% of your coverage, as follows:
$67,500 Basic coverage: 75% x $90,000 = $75,000 Optional coverage: 75% x $100,000 = $142,500 Total benefits
Additional benefits
The plan also offers other benefits, such as:
• increased amounts if you were in a vehicle and wearing a seat belt at the time of the accident;
• home and vehicle alterations; • and more!
Please see “Appendix B: Additional benefits for accidental injury or death” for more information, including applicable limitations and conditions.
1. Report your claim by calling Johnson at (902) 628-3537 or, if you are outside the Charlottetown area, 1 800 371-9516. Johnson will provide you with a claim form.
2. Complete and return the claim form to Johnson within 30 days of the accident. Your claim will still be valid if it is not reasonably possible for you to provide the written notice or proof within the 30-day deadline. However, you must provide notice or proof no later than one year after the accident.
This coverage is available for:
• Civil Service employees in Class 1;
• Civil Service employees in Class 4 (onlytemporary employees working at least 40% of the normal weekly working hours);
• Health Sector employees who transferred from the Province of PEI Civil Service Insurance Plan (transferees) and had long-term disability coverage under that plan;
• Permanent full-time Health PEI PEINU, UPSE, CUPE and IUOE employees working at least 30 hours per week;
• Permanent part-time Health PEI UPSE, CUPE and IUOE employees working less than the fully prescribed hours of work on a recurring and regularly scheduled basis; and
• Permanent part-time Health PEI PEINU employees (with a guarantee of at least 40% of hours per week).
M
ONTHLY BENEFITSLong-term disability benefits are equal to:
These benefits are taxable.
While you receive benefits, an additional percentage of your earnings will be paid on your behalf to cover your contributions to the pension plan.
If you accidentally become disabled, you may also be eligible for a permanent total disability benefit under your accident insurance. Please refer to “Appendix B: Additional benefits for accidental injury or death” for details.
E
NSURING YOUR BENEFITS DO NOT EXCEED YOUR TAKE-
HOME PAYLong-term disability benefits are designed to provide you with a reasonable level of income during a disability. They are not intended to provide you with more income than when you were working. As a result, your long-term disability benefits are reduced by any other income you receive
because of your disability. Please see “Appendix C: Long-term disability details”for a complete list of sources of income that could reduce your long-term disability benefits.
H
ELPING YOU KEEP UP WITH INFLATIONAlthough a disability can put your life on hold, the cost of living keeps on growing. That’s why the PSGIP currently increases benefits on January 1 of each year after your first full calendar year of total disability. This increase is equal to the annual increase in the Consumer Price Index, to a maximum of 3% per year.
If you become disabled
If you become totally disabled, the PSGIP may continue a percentage of your income while you are on long-term disability.
34
70% of your monthly earnings (as defined on page 56) to a maximum benefit of $6,000 per month
What happens if I return to
work after a disability and
become disabled again?
What happens to my other
benefits while I am on
long-term disability?
That will depend on the benefit and your group of employment. Certain benefits could be continued without premium payments. Johnson will provide you with details at that time. 1. Before your sick leave benefits end, call
Johnson at 628-3537 or 1 800 371-9516 to notify them of your disability, even if you are applying for Workers’ Compensation benefits. Be sure to mention the policy number: 165211. A representative will then send you the necessary information, the long-term disability claim form, and the waiver of premium claim form for life (if applicable) and accident insurance.
2. Complete the forms. Your attending physician must also complete a portion of the forms.
3. Return the completed forms to Johnson within six months from the end of the qualifying period.
Benefits continue until the earliest of the following dates: • when you cease to be disabled;
• when you fail to submit to a requested physical examination and/or mental evaluation;
• when you fail to provide satisfactory written proof of continuance of disability;
• when you are no longer receiving regular and ongoing care of a physician;
• when you refuse to enter into (or stop participating in) any rehabilitation program that the insurer considers to be appropriate;
• when you reach age 60 (if your sick leave benefits end after
your 59th birthday, monthly income payments will continue beyond age 60* until a total of 12 monthly payments have been made or your disability ceases); • when you are incarcerated in a prison or mental institution
by authority of a criminal court;
• when you refuse to complete and return a Reimbursement Agreement/Direction form or comply with the terms of a signed Reimbursement Agreement/Direction form, when requested, in accordance with the provisions under third party liability; and
• when you die.
W
HEN BENEFITS BEGINBenefits will begin after the qualifying period has been satisfied, which is the later of:
• the date your accumulated sick leave credits have expired; and • four months of continuous total disability.
You must, however, still be totally disabled at that time.
If the second disability is …
The second disability will be considered … Related to the first
disability and recurs within six months
A continuation of the first disability and benefits will immediately become payable in the same amount, less any accumulated sick leave credits Related to the first
disability and recurs after six months, or is not related to the first disability
A new disability, which means you will receive benefits after your accumulated sick leave credits have expired or four months of continuous total disability, whichever is later
Note: Long-term disability benefits will extend beyond your termination date provided you became disabled while you were still insured. Benefits will continue to be paid according to the contract provisions regardless of the subsequent termination of the group policy. Great-West Life reserves the right to request proof of the continuance of total disability, and to have you submit to an examination by Great-West Life’s medical advisors when requested.
Bon voyage:
Medical emergencies while outside your province
of residence
If you suddenly and unexpectedly become ill or injured while outside your province of residence and you require immediate medical treatment, the plan will provide coverage, as indicated on the right:
You must be eligible for benefits under a government health plan in Canada to qualify
for emergency out-of-province/country coverage or Travel Assistance coverage. Certain limitations and conditions apply.
E
LIGIBLE EXPENSESS
PECIAL NOTESHospitalization Hospital room at the ward rate
Hospital services and supplies also covered
Living expenses for a companion travelling with the patient, to stay with the patient beyond the original return date
Reimbursed up to $150 a day, for a total reimbursement of $1,500 Includes cost of accommodation, meals, telephone and taxi or rental cars The Travel Assistance provider must approve the charges beforehand.
PSGIP
pays 100% Maximum reimbursement:$1 million per emergency above what
your provincial health plan pays Note:Certain expenses, such as prescription drugs, are covered to the same extent as they would be in Canada.
Medical evacuation home or transportation to another medical facility
Economy airfare for transportation home
Referrals to physicians or medical facilities, if necessary
The Travel Assistance provider is not responsible for the actions or advice of any persons that you are referred to.
Return home airfare (economy class) for a travel companion
For a companion who is travelling with the patient and who has forfeited his or her ticket because of a delay caused by the insured person’s illness, injury, or death
The Travel Assistance provider must approve the charges beforehand.
Physician services
E
LIGIBLE EXPENSESS
PECIAL NOTES Return home airfare(economy class) for each child
For each child left alone because of the insured person’s illness, injury, or death
The Travel Assistance provider will also arrange for a qualified attendant to accompany the children, if necessary.
The Travel Assistance provider must approve the charges beforehand.
Return of deceased Reimbursed up to $3,500
Return of vehicle (to insured person’s home or the nearest rental agency)
Reimbursed up to $1,000
The Travel Assistance provider must approve the charges beforehand.
Round-trip economy airfare for a visiting family member
Provided the insured person is travelling alone and must be hospitalized for more than 10 days The Travel Assistance provider must approve the charges beforehand.
Wheelchairs, prescription drugs, crutches, and other eligible expenses under the plan’s health coverage
Covered to the same extent as they would be in Canada
1. When you travel, be sure to carry your Travel Assistance card at all times.
2. If you become ill or injured outside of your home province or Canada and require emergency treatment, you or your representative should immediately call the number on the card. Otherwise, your benefits may be reduced by 40% of covered expenses, with a maximum reimbursement of $25,000.
Calling immediately will enable the Travel Assistance provider to co-ordinate payment directly with the hospital and/or medical provider involved, only if the Travel Assistance provider obtains your approval to co-ordinate payment with the provincial health plan.
3. If a medical provider or hospital bills you directly, send the bill along with your out-of-country claim form to: Assistance Centre - Claims Department, P.O. Box 97, Station A, Mississauga, Ontario L5A 2Y9. You must submit your claim form within 12 months after incurring the expense.
If you have any claims questions or require an out-of-country claim form, please call the Great-West Life Customer Care Centre toll free at 1 800 957-9777.
In the event of an emergency, call the Travel Assistance provider as soon as possible! You’ll find the phone number on your Travel Assistance card or in the benefits phonebook on page 9 of this guide.
Does the plan cover
non-medical services?
Yes, you can also count on thefollowing free services in the event of an emergency:
• multilingual assistance by
telephone, 24 hours a day, 365 days a year, to obtain aid, assistance, and exchange information relating to the covered services;
• arrangements for direct payment, wherever possible, for physicians’ services, hospitalization and other insured services;
• communication with the physician who is treating the insured person to get an understanding of the situation and monitor the condition; • telephone interpretation services
in most major languages; • the sending and receiving of
urgent messages;
• help to locate Embassy or Consulate services; and
• help to locate lost documents or luggage.
38
If your physician or the Travel Assistance Centre recommends that you return to your home province and you choose not to go, your emergency coverage and Travel Assistance coverage will end.
If your physician or the Travel Assistance Centre recommends that you be moved to another facility and you choose not to go, your benefits will be reduced by 40% of covered expenses, with a maximum reimbursement of $25,000.
The importance of following recommendations from
your physician or the Travel Assistance Centre
Your travel coverage does not pay for any expenses incurred directly or indirectly as a result of:
• your pregnancy, if expenses are incurred outside Canada within nine weeks of your expected delivery date;
• the birth of a child born outside of Canada within nine weeks of the expected delivery date, or after the expected delivery date;
• an accident that occurred while you were operating a vehicle, vessel, or aircraft, if you:
- were impaired by drugs or alcohol; or
- had a blood-alcohol level higher than 80 milligrams of alcohol per 100 millilitres of blood;
Can I get a referral for
treatment in the United States?
Yes. The plan covers referrals for treatment in Canada and the United States only.Does somebody have to approve
the referral beforehand?
Yes, Great-West Life.
Getting a referral for treatment outside your
home province
If a physician in your home province gives a written referral for treatment that is not performed in that province, the plan will cover the usual cost of the treatment, as follows:
PSGIP pays 100%
The plan pays the difference between:
• the actual cost; and
• the amount available under the provincial plan, provided the provincial plan is first payer.
1. Before you incur eligible expenses, you must provide Great-West Life with:
• full details from the physician regarding the treatment; and • a statement from the provincial
health plan that describes what it will cover.
2. After you have incurred an eligible expense and the provincial plan has already paid its portion, submit a claim form for the unpaid portion to Great-West Life.
Also see “General exclusions” starting on page 50.
The plan also does not provide coverage as described in this section:
• for emergency treatment while travelling for health reasons;
• once emergency treatment for a condition is completed,
for any ongoing treatment related to that condition; • for medical emergencies in
Milestones:
Becoming a parent
You may enroll your new child in the plan. The definition of a child varies according to the type of coverage. Please refer to page 56 for the applicable definition.
Becoming legally separated or divorced
You may choose to cover your former spouse under your health, dental and travel benefits, if you wish, but you may cover only one spouse. If your spouse is still covered under another group insurance plan, you may still coordinate benefits for your children’s covered expenses between your plan and your former spouse’s plan.
1. Simply follow the same procedure as on page 12.
2. You must also submit proof of good health for your child if you are applying to cover the child more than 31 days after having him or her. Coverage will take effect once Great-West Life approves the proof of good health.
1. Notify Johnson, in writing, of the change in your marital status.
2. Specify that you wish to terminate coverage for your former spouse.