Supplementary Health Insurance

In addition to the benefits available under the provincial government programs, supplementary health insurance is provided to you and your insured dependents as outlined below.

Hospital Benefit
If you or any of your insured dependents are confined in a hospital on the recommendation of a physician, coverage is provided for semi-private hospital room, 100%, to a daily maximum of $85.00

Prescription Drug Benefit
The program will pay the ingredient cost of eligible drugs (including oral contraceptives and insulin), and the employee/retiree will pay the co-pay, which will be the equivalent of the pharmacists professional fee plus any applicable surcharge. The drug plan provides coverage for most drugs which require a prescription by law, however, some drugs may require special authorization, but does not provide coverage for over-the-counter drugs, cough or cold preparations, nicotine products, etc. Details of the special authorization process are outlined in this booklet.

Extended Health Benefit
This portion of the program includes coverage for the following. It is important to note that reimbursement under the extended health care benefit is made at 80% of covered eligible expenses up to $5,000; expenses over $5,000 and less than $10,000 are reimbursed at 90%, and expenses over $10,000 are reimbursed at 100% in any calendar year. Eligible expenses are as stated below. Where no maximum eligible expense is noted , reasonable and customary rates will apply.

• Services of a Registered Nurse, Licensed Practical Nurse and Registered Nursing Assistant, including Home Health Care Services (excluding a relative), in your home to a maximum covered eligible expense of $10,000 per disability. Service must be for active medical care and reimbursement will not be made when the services are custodial in nature. Pre-approval is required;

• Services of a qualified physiotherapist (requires a physician confirmation) massage therapist (requires physician referral stating medical reason) osteopath, chiropodist, chiropractor, naturopath and podiatrist to an annual covered eligible expense of $500 per practitioner (excluding a relative);

• Acupuncture service is covered to an annual eligible expense of $500.

• Purchase of wheelchair cushions to an annual covered eligible expense of $300;

• Casts, trusses, braces, crutches, canes, walkers and splints (excluding dental splints);

• Hearing aids are eligible, one for each ear every three consecutive calendar years. The maximum eligible expense for each hearing aid is $750.

• Artificial limbs (excluding myoelectrical limbs) and eyes and other prosthetic appliances including repair and replacement where the loss of the natural member was incurred while insured;

• Rental or purchase of a wheelchair (every five years), hospital bed, iron lung or other durable equipment. Pre-approval is required;

• Rental or purchase of transcutaneous electrical nerve stimulator (TENS);

• Jobst burn garments, Jobst sleeves for lymphoedema following mastectomy and Jobst support hose and surgical stockings;

• Stump socks;

• Colostomy and ileostomy apparatus;

• External breast prosthesis, once per calendar year, post mastectomy;

• Surgical Brassieres, post mastectomy are added as an eligible benefit providing 80% of a maximum eligible expense of $100 per brassiere. The contract will allow up to two brassieres per calendar year.

• Treatment by x-ray, radium and radioactive isotopes;

• Oxygen, plasma or blood transfusions;

• Up to a covered eligible expense of $20 per day for room and board for active treatment or convalescent care in a licensed nursing home supervised by a Registered Nurse on a 24-hour basis. Confinement in the nursing home must be for rehabilitation or convalescent care and not for custodial care;

• Services of a dental surgeon including dental prosthesis required for treatment of a fractured jaw or for treatment of accidental injuries to natural teeth if reported within six months of the accident where the injury was caused by external, violent and accidental means;

• Injectable drugs when administered by a physician, (Excludes Vaccines);

• Insulin syringes and home chemical testing supplies for diabetics including glucometer and supplies. (Note: Insulin is covered under the prescription drugs benefits portion of the plan). Maximum allowable expense per year is $1,580.

• Insulin pumps are an eligible benefit with effect April 1, 2004, for insured 16 years of age or less. The program will allow 80% reimbursement to a maximum payable of $4,800 in a five year period.

• Insulin pumps are an eligible benefit with effect April 1, 2010, for adults (17yrs and over) on restricted circumstances with a maximum reimbursement of $2,500 every sixty (60) months.

• Up to a covered eligible expense of $500 per year for the services of a psychologist on the written prescription of a psychiatrist or pediatrician;

• The requirement for a Psychiatrist referral will be replaced with a General Medical Practitioner referral. Effective April 1, 2010, the access to a Psychologist with the referral by a General Practitioner will be introduced with a maximum eligible amount per visit of $65 and an annual eligible maximum of $325.

• Up to a covered eligible expense of $500 per year for the services of a speech therapist on the written prescription of a Medical Specialist; and

• Orthopedic shoes and orthopedic aids to a maximum covered eligible expense of $200 every calendar year.

• Services of a qualified Occupational Therapist to an annual eligible covered expense of $500.

Emergency Ambulance Benefit
Emergency Ambulance Benefit is amended for professional ambulance service, including licensed air ambulance services when certified as immediately necessary by the attending physician. Reimbursement covers transportation to and from the nearest hospital of licensed medical facility able to provide treatment for bodily injury or sickness subject to 80% of a covered eligible expense of $1,000 outside the province and $500 within the province. For employees who are residents of Labrador, the benefit is 80% of a covered eligible expense of $500 outside the province and $1,000 within the province. Further, all eligible amounts are now subject to 80% of the maximum eligible expense applicable per person per calendar year.

Non-Emergency Transportation Benefit

• Transportation expenses incurred for non-emergency service to and from the nearest hospital or medical facility which can provide necessary services, including x-rays or examinations, not readily available in the local area to 80% of a covered eligible expense of $300 in respect of all such claims in a calendar year;

• Expenses for an escort, including the parent if the person requiring treatment is under 15 years of age, up to 80% of a covered eligible expense of $300 for each calendar year;

• Services must be prescribed by a physician or surgeon. No benefit is payable for aesthetic surgery (cosmetic surgery for beautification purposes); and

• Any expenses incurred for meals or accommodations will not be considered as eligible expenses.

Note
Benefits for transportation expenses shall be paid only if:

1. written documentation and confirmation is received from the physician who prescribed the treatment and the hospital or medical facility that rendered the treatment, that such treatment was actually rendered.

2. the nearest hospital or medical facility able to provide the necessary treatment was at least 80 kilometres or 160 kilometres round trip by the most direct route, from your city, town or community of residence; and

3. the most economical means of transportation available was used or the physician provides written documentation that an alternate, more expensive means was necessary due to the patient's medical condition. Where a private vehicle is used, a maximum of

4. $0.125 per kilometre would be paid, but in no event shall this exceed the cost of the most economical means available.

Vision Care Benefit
You and your insured dependents are covered for the following vision care expenses:

1. Up to 80% of charges for eye examinations performed by an Ophthalmologist or Optometrist where the Medicare plan does not cover such services, limited to one such expense in a calendar year for dependent children under age 18 and once in two calendar years for all other insured persons;

2. Up to 100% of covered eligible expense of $150 for single lenses and frames and 100% of a covered eligible expense of $200 for bifocal lenses and frames limited to one expense in every three calendar years. And $225 for trifocal lenses and frames limited to one expense in every three calendar years. Once in a calendar year for dependent children under age 18 if a change in the strength of the prescription is required. Please note that expenses for contact lenses will be reimbursed at the same level as for eyeglasses. Coverage is not provided for sunglasses, safety glasses, or repairs and maintenance.

3. Coverage for "laser eye surgery" to a one time maximum amount of $450. If a claim is made for this benefit, no further vision care will be payable for six (6) years.

4. Up to 100% of the covered eligible expense of $250 in two calendar years for the purchase of contact lenses prescribed for severe corneal scarring, keratoconus or aphakia, provided vision can be improved to at least a 20/40 level by contact lenses, but cannot be improved to the level by spectacle lenses. If contact lenses are selected for cosmetic reasons, you will be eligible for up to the eyeglasses maximum once in any two calendar years. Dependent children will be eligible for this benefit once in any calendar year, provided that a change in the strength of the prescription is required;

5. One pair of eyeglasses when prescribed by an Ophthalmologist following surgery, to 100% of a lifetime covered eligible expense of $200; and

6. 50% of the cost of visual training or remedial therapy.

Out-of Province Benefit
Coverage is provided for 80% of expenses incurred outside your home province when the required medical treatment is not readily available in your home province.

If the medical treatment is readily available elsewhere in Canada but you seek treatment outside Canada, benefits will be limited to the reasonable and customary charges of the nearest Canadian medical centre equipped to provide the necessary treatment. It is suggested that you submit a treatment plan so the insurer can advise you of the amount payable before you incur the expense.

Coverage is provided for the following:

• semi-private hospital accommodation;
• hospital out-patient services;
• physicians' fees;
• laboratory tests and x-rays; and
• other eligible expenses that would have been covered in your home province.

Co-ordination of Benefits
Should similar benefits be provided by more than one section of the policy, any claim for these benefits will be assessed by the Insurance Company in a manner which provides the greatest benefit to the participant.

Where compensation for benefits covered under this plan is available to a participant under any other prepaid health service contract or insurance policy, the amount payable under this plan shall be coordinated with such other coverages in accordance with the Canadian Life and Health Insurance Association (CLHIA) Guidelines so that the total benefits from all plans will not exceed the expenses actually incurred.

Effective April 1, 2010, Co-ordination of Benefits will be allowed between spouses insured under the Plan.

If the other plan does not contain a coordination of benefits provision, then that plan shall be considered first payer.

Conversion Privilege
If you should terminate employment prior to age 65, you may convert to an individual health plan currently offered by the insurer, provided that application is made within 31 days following your date of termination. After 31 days following your date of termination, medical evidence of insurability will be required.

Services not Covered Under the Supplementary Health Insurance Program
You and/or your dependents are not covered for medical expenses incurred as a result of any of the following:

• injury or illness due to war or engaging in a riot or insurrection;

• aesthetic surgery (cosmetic surgery for beautification purposes) - services required due to an intentional self-inflicted injury;

• delivery charges;

• hearing tests;

• pregnancy tests;

• injury or illness for which you or your dependents are covered under Worker's Compensation or a similar program;

• services or supplies received from a dental or medical department maintained by your employers, a mutual benefit association, labour union, trustee or similar type group;

• services or supplies which are covered under a government hospital plan, a government health plan or any other government plan;

• expenses for contraceptives other than oral contraceptives;

• expenses for vitamins (except injectables), minerals, and protein supplements (other than expenses than would qualify for reimbursement under Eligible Expenses under the Drug Benefit);

• expenses for diets and dietary supplements, infant foods and sugar or salt substitutes;

• expenses for drugs which are used for a condition or conditions not recommended by the manufacturer of the drugs; and

• experimental products or treatments for which substantial evidence provided through objective clinical testing of the product's a treatment's safety and effectiveness for the purpose and under the conditions of the use recommended does not exist to the satisfaction of the administrator.

• expenses for lozenges, mouth washes, non-medicated shampoos, contact lens care products and skin cleaners, protectives, or emollients.