GROUP INSURANCE PLAN Contract 6000 FTQ

Transcription

1 (Isurer) FTQ Itersectoral Parity Committee (Policyholder) GROUP INSURANCE PLAN Cotract 6000 FTQ School Sector for wage-earers represeted by Pla modified o Jauary 1, 2016

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3 THE GROUP INSURANCE PLANS FOR CONTRACT 6000 ARE OFFERED TO WAGE-EARNERS WHO ARE MEMBERS OF THE FOLLOWING FTQ-AFFILIATED UNIONS: HEALTH AND SOCIAL SERVICES SECTOR Caadia Uio of Public Employees (CUPE) Sydicat québécois des employés et employées de service, Local 298 (SQEES) Caadia Office ad Professioal Employees Uio Québec (SEPB Québec) ELEMENTARY AND SECONDARY EDUCATION SECTOR Caadia Uio of Public Employees (CUPE) Service Employees Uio (UES-800) Caadia Office ad Professioal Employees Uio Québec (SEPB Québec) COLLEGE EDUCATION SECTOR Caadia Uio of Public Employees (CUPE) ORGANIZATIONS SOCIÉTÉ QUÉBÉCOISE DES INFRASTRUCTURES (SQI) SOCIÉTÉ DE DÉVELOPPEMENT DES ENTREPRISES CULTURELLES (SODEC) MUSÉE NATIONAL DES BEAUX-ARTS DU QUÉBEC SOCIÉTÉ QUÉBÉCOISE D INFORMATION JURIDIQUE (SOQUIJ) LA FÉDÉRATION DES COMMISSIONS SCOLAIRES DU QUÉBEC (FCSQ) INSTITUT NATIONAL DE SANTÉ PUBLIQUE DU QUÉBEC (INSPQ) Caadia Uio of Public Employees (CUPE) RÉGIE DE L ÉNERGIE Caadia Office ad Professioal Employees Uio Québec (SEPB Québec)

4 THIS BOOKLET IS FOR WAGE-EARNERS WORKING IN ESTABLISHMENTS REPRESENTED BY: ELEMENTARY, SECONDARY AND COLLEGE EDUCATION SECTOR Miistère de l Éducatio, du Loisir et du Sport (MELS) La Fédératio des commissios scolaires du Québec (FCSQ) Quebec Eglish School Boards Associatio (QESBA) Fédératio des cégeps

5 YOUR GROUP INSURANCE PLAN IMPORTANT The Policyholder may at ay time, upo agreemet with the Isurer, make modificatios to the cotract with respect to the idividuals eligible for isurace, the scope of coverage ad the sharig of costs amog classes of isureds. Ay such modificatios shall the apply to all isureds, whether they are active, disabled or retired. This booklet does ot iclude all the cotractual clauses regardig defiitios, eligibility, erolmet, effective date ad termiatio of isurace ad other specificatios. For more iformatio about the cotets, you may cosult the admiistrative guide available from your employer or obtai a copy of the policy by cotactig the local uio represetative. This booklet is produced for iformatio purposes oly ad i o way modifies the terms ad coditios of the cotract.

6 100% The electroic versio of this booklet is available olie at uder Idividuals/Group isurace/iformatio for isureds. This booklet is prited o paper made from 100% post-cosumer recycled material. A simple gesture that goes a log way to help protect our eviromet ad the resources aroud us.

7 TABLE OF CONTENTS INSURANCE PLANS Schedule of Isurace... 9 Isurace Plas Complete Basic Health Isurace Pla Reduced Basic Health Isurace Pla Optioal Exteded Health Isurace Pla Optio I Optioal Detal Care Isurace Pla Optio II Active Participat s ad Retiree s Optioal Life Isurace Pla Optio III Active participats a) Participat s Basic Life Isurace b) Participat s Optioal Life Isurace c) Participat s Accidetal Death ad Dismembermet Isurace d) Participat s Spouse s ad Depedet Childre s Life Isurace e) Participat s Spouse s Optioal Life Isurace Retired participats a) Retiree s Life Isurace b) Retiree s Spouse s ad Depedet Childre s Life Isurace c) Retiree s Spouse s Optioal Life Isurace Accelerated beefit paymet i the evet of termial illess GENERAL INFORMATION CLAIMS PROCEDURE Geeral Iformatio Claims Procedure Travel Isurace TRAVEL INSURANCE TRIP CANCELLATION INSURANCE Trip Cacellatio Isurace 7

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9 INSURANCE PLANS Schedule of Isurace Isurace Plas The followig tables preset a brief summary of the coverage provided uder the plas for active ad retired participats ad a summary of the beefits payable uder Cotract For a full descriptio of each pla, please refer to the correspodig pages i the booklet. ACTIVE PARTICIPANTS Complete Basic Health Isurace Pla (page 13) (Madatory participatio) Prescriptio drugs ad other expeses 80% of the first $2,500 of eligible expeses ad 100% of ay excess Automated paymet service Direct Coagulatio self-moitorig device 100%, up to the maximums specified o (CoaguChek) pages 16 ad 17 Hearig aid Trip Cacellatio Isurace 100%, maximum per trip, per isured: $5,000 Travel Isurace 100%, lifetime maximum: $5,000,000 Blood glucose moitor Detoxificatio Hospitalizatio i a semi-private room Itrauterie device (IUD) 100%, up to the maximums specified o pages 16 ad 17 Reduced Basic Health Isurace Pla (page 19) (Madatory participatio) Prescriptio drugs 71% of the first $2,586 of eligible expeses ad 100% of ay excess Automated paymet service Direct Travel Isurace 100%, lifetime maximum: $5,000,000 Trip Cacellatio Isurace 100%, maximum per trip, per isured: $5,000 Detists fees i the evet of accidetal 71% of the first $2,586 of eligible damage to atural teeth expeses ad 100% of ay excess 9

10 Chiropractor ACTIVE PARTICIPANTS Exteded Health Isurace Pla (Optio I) (Page 22) (Optioal participatio for a miimum period of 36 moths) Healthcare professioals Homeopath, osteopath, aturopath, acupucturist or dietitia Kiesitherapist, orthotherapist, kiotherapist ad massage therapist Physiotherapist ad physical rehabilitatio therapist Podiatrist ad foot care urse Psychologist, psychiatrist, psychoaalyst, psychotherapist ad social worker Registered urse or ursig assistat Ultrasoud examiatios (excludig fetal) ad thermographic evaluatios X-rays 80%, up to a maximum reimbursemet of $20 per treatmet ad $400 per caledar year 80%, up to a maximum reimbursemet of $20 per treatmet ad $400 per caledar year, per specialist 80%, up to a overall maximum reimbursemet of $20 per treatmet ad $400 per caledar year, for all of these specialists 80%, up to a overall maximum reimbursemet of $20 per treatmet ad $400 per caledar year, for all of these specialists 80%, up to a overall maximum reimbursemet of $20 per treatmet ad $400 per caledar year, for all of these specialists 50%, up to a overall maximum reimbursemet of $500 per caledar year, for all of these specialists 80%, up to a maximum reimbursemet of $200 per day ad $4,000 per caledar year Other expeses 80%, up to a overall maximum reimbursemet of $400 per caledar year, for all of these expeses 80%, up to a maximum reimbursemet of $40 per caledar year 10

11 ACTIVE PARTICIPANTS Detal Care Isurace Pla (Optio II) (page 24) (Optioal participatio for a miimum period of 36 moths) 80%* Diagostic, prevetive, basic restorative ad major restorative services Fixed prosthodotics Removable prosthodotics Automated paymet service 50%* * Up to a maximum reimbursemet of $1,000 per caledar year, for all of these expeses 80%, up to a maximum reimbursemet of $1,000 per caledar year, 1 replacemet per period of 4 cosecutive years Direct Isurace Plas Life Isurace Pla (Optio III) (Page 35) (Optioal participatio) Participat s Basic Life Isurace Uder age 65: 1 times the salary Age 65 or over: 1 /2 the salary Participat s Accidetal Death ad Uder age 65: 1 times the salary Dismembermet Isurace Age 65 or over: 1 /2 the salary Participat s Optioal Life Isurace 1 to 5 times the salary Spouse s Life Isurace $5,000 Depedet Childre s Life Isurace $2,500 Spouse s Optioal Life Isurace 1 to 20 uits of $5,000 This pla provides for a accelerated beefit paymet i the evet of termial illess. RETIRED PARTICIPANTS Life Isurace Pla (Optio III) (page 37) (Optioal participatio) Upo retiremet, participats may apply for, uder the retired participat s group life isurace, the beefits they held uder the active participats life isurace pla immediately prior to retiremet. All applicatios must be submitted withi 30 days followig the retiremet date. The form may be obtaied from the employer or dowloaded from the Isurer s website at uder Idividuals/Group Isurace/Iformatio for Isureds/Itersectoral Parity Committee (Group 6000). 11

12 RETIRED PARTICIPANTS (cot.) LIFE INSURANCE COVERAGE TABLE Retiree s Life Isurace 1 to 20 uits of $5,000, up to the amout held before retiremet Spouse s Life Isurace $5,000 Depedet Childre s Life Isurace $2,500 Spouse s Optioal Life Isurace 1 to 20 uits of $5,000, up to the amout held before retiremet This pla provides for a accelerated beefit paymet i the evet of termial illess. Idividual Healthcare Isurace product Policy 3992 (Optioal participatio) Participats who are retirig ad are ot eligible for aother group Health isurace pla that icludes prescriptio drug isurace must register for coverage with the Régie de l assurace maladie du Québec (RAMQ). They may also apply for the idividual Healthcare Isurace product Policy 3992, which also icludes Travel ad Trip Cacellatio isurace. Participats may choose betwee 3 plas: Basic, Itermediate ad Eriched. A optioal coverage supplemet is also available for Detal Care ad Visio Care isurace, as well as for the reimbursemet of the deductible ad coisurace required for prescriptio drugs eligible uder the RAMQ s Prescriptio Drug Isurace Pla. All applicatios must be submitted withi 60 days followig the retiremet date or the date of termiatio of the pla which eabled the exemptio. Beyod this period, evidece of isurability will be required. The documets required for erolmet (leaflet ad erolmet form) may be obtaied from the employer or dowloaded from the Isurer s website at uder Idividuals/Group Isurace/Iformatio for Isureds/Itersectoral Parity Committee (Group 6000). 12

13 COMPLETE BASIC HEALTH INSURANCE PLAN Madatory participatio Isurace Plas Eligible expeses are reasoable expeses that are justified by the seriousess of the case as well as by curret medical practice ad customary charges, ad icurred by a isured followig a accidet, illess, pregacy or surgical procedure related to family plaig or orga or boe marrow doatio. 1. The followig expeses are reimbursed at 80% for participats ad their depedets, if applicable, ad at 100% oce the total expeses exceed $2,500 i a give caledar year. a) Expeses for drugs prescribed by a physicia or a detist ad dispesed by a licesed pharmacist or by a duly authorized physicia, subject to the followig exclusios: The term prescriptio drugs refers to products icluded i the drug formulary of the Régie de l assurace maladie du Québec (RAMQ) or i the drug formulary of the Associatio québécoise des pharmacies propriétaires (AQPP), with the exceptio of drugs coded V or Z. The followig products are ot cosidered to be prescriptio drugs: Products cosidered to be food substitutes, cosmetic products, soaps, suscrees ad taig oils, ski emolliets, shampoos ad other products for scalp treatmet, except o medical recommedatio deemed satisfactory by the Isurer Dietetic substaces or foods Homeopathic medicies Ay substaces used for the purpose of isemiatio, ad cotraceptive ad prophylactic jellies ad foams Prevetive vaccies Ijectios provided as part of a weight reductio program Over-the-couter laxatives ad atacids, except o medical recommedatio deemed satisfactory by the Isurer Drugs or substaces used for the treatmet of impotece 13

14 Drugs admiistered primarily for prevetive purposes Smokig cessatio products (except those icluded o the RAMQ list) Drugs admiistered for aesthetic purposes, except if required due to a accidet. Notwithstadig ay defiitio or the above-metioed exclusios, all prescriptio drugs that must be covered uder the group isurace cotract i accordace with the Quebec Act respectig prescriptio drug isurace are cosidered to be eligible expeses. For ay drug approved after Jauary 1, 1997, the Isurer reserves the right, upo agreemet with the Committee: to limit the reimbursemet accordig to the criteria stipulated by the regulatio regardig the Quebec Act respectig prescriptio drug isurace, if it is registered as a exceptio drug o the list uder sectio 60 of the Act to exclude it or establish the reimbursemet criteria if it is ot icluded o said list. b) Trasportatio to hospital by ambulace (roud trip), icludig emergecy or medically required air or rail trasportatio. c) Expeses for the purchase of artificial limbs, exteral prostheses, trusses, special badages (severe burs), corsets, crutches, splits, casts, artificial eyes, support stockigs with a compressio ratio of 13 mm Hg or more (maximum 4 pairs per caledar year), icurred o medical recommedatio ad required by the isured s physical coditio. For the purposes of this pla, breast ad capillary prostheses (wigs) are ot cosidered to be exteral prostheses. d) Expeses that exceed those payable by the RAMQ for the purchase of breast prostheses followig a mastectomy, up to a eligible maximum of $500 per period of 24 cosecutive moths, per isured. e) Expeses for the purchase of a iitial capillary prosthesis (wig) required followig chemotherapy or radiotherapy treatmets, up to a eligible maximum of $700 per caledar year, per isured. f) Expeses for the purchase, retal or replacemet of ay product or equipmet required by the isured s physical coditio made by a orthotist-prosthesist or other professioal specialized i the maufacturig of such equipmet or products ad prescribed by a physicia (e.g. compressio garmet for bur victim, device other tha a foot orthosis, kee brace, device for asthmatics). These expeses are eligible for reimbursemet oce per caledar year, per isured. 14

15 g) Expeses for the retal, repair or purchase of a basic model if this optio is deemed more ecoomical, of a wheelchair, a hospital bed (excludig the mattress) or a breathig assistace apparatus. h) Expeses icurred for the followig services ad supplies provided uder medical supervisio or o prescriptio ad ot otherwise eligible for reimbursemet: Audiology Ijectable medicatios, with the exceptio of professioal fees Laboratory tests Occupatioal therapy Oxyge therapy Speech therapy Test strips, syriges ad eedles for diabetics. i) Expeses for the substace used i sclerosig ijectios, with the exceptio of professioal fees, if treatmet is medically required, up to a maximum reimbursemet of $30 per treatmet ad 10 treatmets per caledar year, per isured. j) Professioal services of a detist to repair accidetal damage to atural teeth occurrig after the isurace is i force ad provided that the treatmet takes place withi 12 moths followig the date of the accidet. k) Expeses for the purchase of orthopedic shoes that are custom-desiged ad made for a isured from a mould to correct a foot defect, icludig straight, flared or ope shoes, as well as shoes required for Deis Browe splits, up to a maximum of three pairs per caledar year, per isured. The cost of additios or modificatios to shoes is also eligible. This equipmet must be made by a specialized orthopedic laboratory licesed uder the Public Health Protectio Act (R.S.Q., Chapter P.35). l) Expeses for the purchase of foot orthoses, up to a eligible maximum of $525, per caledar year, per isured, for a adult or a child. These orthoses must be made by a specialized orthopedic laboratory licesed uder the Public Health Protectio Act (R.S.Q., Chapter P.35). m) Expeses for a eye examiatio carried out by a ophthalmologist or optometrist for isureds age 18 to 64, up to a maximum reimbursemet of $40 per period of 24 cosecutive moths, per isured. Isurace Plas 15

16 ) Trasport ad accommodatio for remote areas If, o medical prescriptio, a isured is required to travel outside his or her area of residece to cosult or receive treatmet from a medical specialist ot available i the isured s area of residece, the followig expeses are eligible, up to a maximum reimbursemet of $1,000 per caledar year, per isured: Expeses for travel with a public carrier (bus, plae, boat or trai) or by automobile if the situatio requires roud-trip travel of at least 400 kilometres from the isured s place of residece to the place where the isured is required to cosult with or receive treatmet from a medical specialist. However, whe travellig by automobile, eligible expeses are equal to those that would have bee icurred had the trip bee made by bus. Expeses for accommodatio icurred i a public establishmet, up to a eligible maximum of $60 per day, provided the cosultatio or treatmet requires a overight stay. Eligible expeses must be icurred for cosultatios or treatmets i the provice of Quebec ad are reimbursed o productio of receipts or paid ivoices, except if the meas of trasport used is a automobile. If the participat has Idividual coverage, eligible expeses must be icurred for ad explicitly apply to the participat. If the participat has Family or Sigle-Paret coverage, eligible expeses must be icurred for ad explicitly apply to the participat or depedets. This coverage allows for the presece of a perso accompayig the isured, if justified by the situatio. The expeses reimbursed are those exceedig the amouts reimbursed by the Régie de l assurace maladie du Québec (RAMQ). 2. The followig expeses are reimbursed at 100%. a) Blood glucose moitor Expeses icurred for the purchase or repair of a blood glucose moitor, up to a maximum reimbursemet of $250 per period of 60 cosecutive moths, per isured, upo presetatio of a complete report from the attedig physicia statig that the isured is isuli-depedet ad that his or her coditio requires the use of this appliace. 16

17 b) Coagulatio self-moitorig device (CoaguChek) Expeses for the purchase or repair of a coagulatio self-moitorig device, if such a device is required due to the isured s medical coditio ad it is obtaied o medical recommedatio. The expeses are limited to a maximum reimbursemet of $500 per period of 60 cosecutive moths, per isured. c) Detoxificatio I the evet of rehabilitatio treatmet for alcoholism or drug use, excludig addictio to the use of tobacco, eligible expeses are provided for a stay i a establishmet officially recogized for such purpose, subject to a maximum reimbursemet of $40 per day ad $1,000 per caledar year, per isured. d) Hearig aid Expeses icurred for the purchase or repair of a hearig aid, up to a maximum reimbursemet of $500 per period of 36 cosecutive moths, per isured. e) Hospitalizatio i a semi-private room Hospitalizatio expeses that are icurred i Caada i excess of amouts payable uder ay govermet isurace pla, up to the cost of a semi-private room for each day of hospitalizatio at the rates i force i the provice i which the expeses are icurred, without ay limit as to the umber of days. f) Itrauterie device (IUD) Expeses for the purchase of a itrauterie device (IUD), up to a maximum reimbursemet of $100 per period of 24 cosecutive moths, per isured. g) Travel Isurace A full descriptio of each beefit is provided o Page 67 of the booklet. Maximums apply. h) Trip Cacellatio Isurace A full descriptio of this beefit is provided o Page 75 of the booklet. Maximums apply. Isurace Plas 3. Exclusios Subject to the provisios of the Quebec Act respectig prescriptio drug isurace, o beefit is payable for expeses icurred: For the purchase or adjustmet of detal prostheses, eyeglasses or cotact leses. For hearig examiatios. 17

18 For periodic medical examiatios, medical examiatios for the purposes of employmet, admissio to a educatioal istitutio or isurace, or required for health trips. Due to self-mutilatio, regardless of the isured s state of mid at that time. For plastic surgery. For ay coditio occurrig while the isured is o active duty with the armed forces. For treatmet, services or products that the isured is ot required to pay. For expeses payable uder ay public or private, idividual or group pla. Ay such expeses are deducted from ay beefits payable uder this pla. Active participatio i a isurrectio, whether real or appreheded. Followig the isured s participatio i a crimial act. I the evet of hospitalizatio for exteded care. Expeses for a stay i a receptio cetre, icludig hospital cetres providig the same type of service (accommodatio) or ay other establishmet, are ot eligible for reimbursemet. For ay user charge, deductible or coisurace required by ay public pla for products ad services eligible for reimbursemet uder this pla. These exclusios also apply to the Travel Isurace beefit i additio to those icluded i the descriptio for that coverage. 18

19 REDUCED BASIC HEALTH INSURANCE PLAN Madatory participatio Isurace Plas Eligible expeses are reasoable expeses that are justified by the seriousess of the case as well as by curret medical practice ad customary charges, ad icurred by a isured followig a accidet, illess, pregacy or surgical procedure related to family plaig or orga or boe marrow doatio. 1. The followig expeses are reimbursed at 71% for participats ad their depedets, if applicable, ad at 100% oce the total expeses exceed $2,586 i a give caledar year. a) Expeses for drugs prescribed by a physicia or a detist ad dispesed by a licesed pharmacist or by a duly authorized physicia, subject to the followig exclusios: The term prescriptio drugs refers to products icluded i the drug formulary of the Régie de l assurace maladie du Québec (RAMQ) or i the drug formulary of the Associatio québécoise des pharmacies propriétaires (AQPP), with the exceptio of drugs coded V or Z. The followig products are ot cosidered to be prescriptio drugs: Products cosidered to be food substitutes, cosmetic products, soaps, suscrees ad taig oils, ski emolliets, shampoos ad other products for scalp treatmet, except o medical recommedatio deemed satisfactory by the Isurer Dietetic substaces or foods Homeopathic medicies Ay substaces used for the purpose of isemiatio, ad cotraceptive ad prophylactic jellies ad foams Prevetive vaccies Ijectios provided as part of a weight reductio program Over-the-couter laxatives ad atacids, except o medical recommedatio deemed satisfactory by the Isurer Drugs or substaces used for the treatmet of impotece 19

20 Drugs admiistered primarily for prevetive purposes Smokig cessatio products (except those icluded o the RAMQ list) Drugs admiistered for aesthetic purposes, except if required due to a accidet. Notwithstadig ay defiitio or the above-metioed exclusios, all prescriptio drugs that must be covered uder the group isurace cotract i accordace with the Quebec Act respectig prescriptio drug isurace are cosidered to be eligible expeses. For ay drug approved after Jauary 1, 1997, the Isurer reserves the right, upo agreemet with the Committee: to limit the reimbursemet accordig to the criteria stipulated by the regulatio regardig the Quebec Act respectig prescriptio drug isurace, if it is registered as a exceptio drug o the list uder sectio 60 of the Act to exclude it or establish the reimbursemet criteria if it is ot icluded o said list. 2. The followig expeses are reimbursed at 71% for participats ad their depedets, if applicable, ad at 100% oce the total expeses exceed $2,586 i a give caledar year. a) Professioal services of a detist to repair accidetal damage to atural teeth occurrig after the isurace is i force ad provided that the treatmet takes place withi 12 moths followig the date of the accidet. 3. The followig expeses are reimbursed at 100%. a) Travel Isurace A full descriptio of this beefit is provided o Page 67 of the booklet. Maximums apply. b) Trip Cacellatio Isurace A full descriptio of this beefit is provided o Page 75 of the booklet. Maximums apply. 20

21 4. Exclusios Subject to the provisios of the Quebec Act respectig prescriptio drug isurace, o beefit is payable for expeses icurred: For the purchase or adjustmet of detal prostheses, eyeglasses or cotact leses. For hearig examiatios. For periodic medical examiatios, medical examiatios for the purposes of employmet, admissio to a educatioal istitutio or isurace, or required for health trips. Due to self-mutilatio, regardless of the isured s state of mid at that time. For plastic surgery. For ay coditio occurrig while the isured is o active duty with the armed forces. For treatmet, services or products that the isured is ot required to pay. For expeses payable uder ay public or private, idividual or group pla. Ay such expeses are deducted from ay beefits payable uder this pla. Active participatio i a isurrectio, whether real or appreheded. Followig the isured s participatio i a crimial act. I the evet of hospitalizatio for exteded care. Expeses for a stay i a receptio cetre, icludig hospital cetres providig the same type of service (accommodatio) or ay other establishmet, are ot eligible for reimbursemet. For ay user charge, deductible or coisurace required by ay public pla for products ad services eligible for reimbursemet uder this pla. Isurace Plas These exclusios also apply to the Travel Isurace beefit i additio to those icluded i the descriptio for that coverage. 21

22 OPTIONAL EXTENDED HEALTH INSURANCE PLAN Optio I Optioal participatio for a miimum period of 36 moths Eligible expeses are reasoable expeses that are justified by the seriousess of the case as well as by curret medical practice, ad icurred by a isured followig a accidet, illess, pregacy or surgical procedure related to family plaig or orga or boe marrow doatio. NOTE: Healthcare professioals must be members i good stadig of their professioal order or of a professioal associatio, or must be recogized by the Committee ad the Isurer. They must work withi the legal scope of their practice. 1. The followig expeses are reimbursed at 80%. a) Professioal services of a chiropractor, up to a maximum reimbursemet of $20 per treatmet ad $400 per caledar year, per isured. Oly oe treatmet per day, per isured, is eligible for reimbursemet. The iitial examiatio doe by the chiropractor is eligible i the same capacity as a treatmet, it beig uderstood that oly oe of these two services is eligible for reimbursemet if both are received o the same day. b) Professioal services of a registered urse or ursig assistat for medical care provided i the isured s home, excludig ay perso who usually resides i the isured s home or is a member of the isured s family, up to a maximum reimbursemet of $200 per day ad $4,000 per caledar year, per isured. c) Professioal services of a homeopath, a osteopath, a aturopath, a acupucturist or a dietitia, up to a maximum reimbursemet of $20 per treatmet ad $400 per caledar year, per isured, per specialist. Oly oe treatmet per day, per specialist, per isured, is eligible for reimbursemet. d) Professioal services of a physiotherapist ad a physical rehabilitatio therapist, up to a overall maximum reimbursemet of $20 per treatmet ad $400 per caledar year, per isured, for all of these specialists. Oly oe treatmet per day, per isured, is eligible for reimbursemet. 22

23 e) Professioal services of a podiatrist ad a foot care urse, up to a overall maximum reimbursemet of $20 per treatmet ad $400 per caledar year, per isured, for all of these specialists. Oly oe treatmet per day, per isured, is eligible for reimbursemet. f) Professioal services of a kiesitherapist, a orthotherapist, a kiotherapist ad a massage therapist, up to a overall maximum reimbursemet of $20 per treatmet ad $400 per caledar year, per isured, for all of these specialists. Oly oe treatmet per day, per specialist, per isured, is eligible for reimbursemet. g) Expeses for X-rays required for the treatmet provided by a specialist covered uder Optio I, up to a overall maximum reimbursemet of $40 per caledar year, per isured, for all of the specialists covered uder this pla. h) Expeses for ultrasoud examiatios ad thermographic evaluatios, excludig fetal ultrasouds, up to a overall maximum reimbursemet of $400 per caledar year, per isured, for all of these expeses icurred o medical prescriptio. Isurace Plas 2. The followig expeses are reimbursed at 50%. Professioal services of a psychologist, a psychiatrist, a psychoaalyst, a psychotherapist ad a professioal social worker are reimbursed up to a overall maximum of $500 per caledar year, per isured, for all of these specialists. Oly oe treatmet per day, per specialist, per isured, is eligible for reimbursemet. The oly professioal services of psychiatrists eligible for reimbursemet are those redered as psychoaalytic treatmets, isofar as these professioals are members of the Caadia Psychoaalytic Society. 3. Exclusios The exclusios provided for the Basic Health Isurace Pla also apply to the Exteded Health Isurace Pla. 23

24 OPTIONAL DENTAL CARE INSURANCE PLAN Optio II Before icurrig ay major treatmet expeses, participats should first check with the Isurer as to the amouts that may be eligible for reimbursemet. To do so, they should use the Caadia Detal Associatio or the Associatio des chirurgies detistes du Québec (ACDQ) detal claim form available i the detist s office, or the Isurer s Detal Claim Form available through their employer or olie, specifyig Treatmet Pla. Optioal participatio for a miimum period of 36 moths Eligible expeses are expeses for treatmet reasoably provided ad recommeded by a detist, up to the amout of the fees specified i the fee guide approved by the Associatio des chirurgies detistes du Québec (ACDQ) at the time services are redered. The Isurer reimburses 80% of expeses for the diagostic, prevetive, basic restorative ad major restorative services ad 50% of expeses for fixed prosthodotics described below, up to a overall maximum reimbursemet of $1,000 per caledar year, per isured, for all of these expeses. The Isurer reimburses 80% of expeses for removable prosthodotics. These expeses are eligible up to a maximum reimbursemet of $1,000 per caledar year, per isured. See restrictios o Page 33. The codes used i the descriptio are draw from the documet etitled 2014 Fee Guide ad Descriptio of Detal Treatmet Services approved by the Associatio des chirurgies detistes du Québec (ACDQ). For subsequet years, these codes are replaced by their equivalets from later documets approved by the Associatio. All ew detal procedure code umbers related to the followig expeses, added while the cotract is i force, are automatically recogized. 1. Eligible expeses Descriptio of diagostic services Cliical oral examiatio a) Complete examiatio: up to oe examiatio per period of 9 cosecutive moths (01110, 01120, 01130) b) Recall or periodic examiatio: up to oe examiatio per period of 9 cosecutive moths (01200) 24

25 c) Detal examiatio for depedet childre uder age 10, if ot covered uder the public pla provided by the Régie de l assurace maladie du Québec: up to oe examiatio per period of 12 cosecutive moths (01250) d) Emergecy examiatio (01300) e) Specific oral examiatio: up to oe examiatio per period of 9 cosecutive moths (01400, 01600, 01700) f) Complete periodotal examiatio: up to oe examiatio per period of 36 cosecutive moths (01500) Limitatio: Oly oe recall, periodic, specific or complete oral examiatio is covered per period of 9 cosecutive moths. However, ay examiatio carried out by a specialist o the recommedatio of a detist (eligible accordig to the ACDQ fee guide) is ot subject to this limitatio. Radiographs a) Itraoral radiographs i) Radiograph, periapical (02111 to 02116) ii) Occlusal film (02131, 02132) iii) Bitewig film (02141 to 02144) iv) Radiograph of soft tissue (02151, 02152) b) Extraoral radiographs i) Extraoral film (02201, 02202) ii) Radiograph, sius (02304) iii) Radiograph, sialography (02400) iv) Radiopaque dyes (02430) v) Radiograph, temporomadibular joit (02504) vi) Paoramic film (02600) vii) Cephalometric film (02701, 02702) c) Radiograph, had ad wrist, as diagostic aid for detal treatmet (02915) d) Tomography (02920, 02929) Limitatio: No more tha oe series of radiographs is eligible for reimbursemet per period of 9 cosecutive moths, except for a series of radiographs take durig a emergecy examiatio or a examiatio carried out by a specialist o the recommedatio of a detist. Furthermore, a complete series of periapical ad bitewig films is eligible for reimbursemet oly oce per period of 36 cosecutive moths. Isurace Plas 25

26 Tests ad laboratory examiatios a) Bacteriological culture to idetify pathological agets (04100) b) Bacteriological culture to determie susceptibility to cavities (04201) c) Biopsy of soft tissue or hard tissue (04302, 04311, 04312) d) Cytology tests (04401, 04402) Diagostic casts a) Umouted (04501, 04502) b) Mouted (04510, 04520) c) Diagostic wax-up (04730) Presetatio of case/treatmet pla (05101) Cosultatio (04500, 05201) Descriptio of prevetive services Polishig of coroal portio of teeth (prophylaxis): up to oe treatmet per period of 9 cosecutive moths (11100, 11200, 11300) Periodotal scalig: up to oe treatmet per period of 9 cosecutive moths for all related detal procedures (43411 to 43414, 43417, 43419) Topical applicatio of fluoride: up to oe treatmet per period of 9 cosecutive moths (12400) Nutritioal cousellig (13100) Oral hygiee istructio (13200, 13210) Plaque cotrol program (13220) Fiishig restoratios (13300) Removal of subgigival fillig material, requirig aesthesia, without flap, per tooth (13301) Pit ad fissure sealats (13401, 13404) Mouth guard (13510) Tooth discig a) Iterproximal discig of teeth (13700) b) Eameloplasty, per tooth (13715) 26

27 Space maitaiers a) Bad type (15108 to 15111, 15120) b) Stailess steel crow type (15200, 15210) c) Removable appliace (15400, 15410) d) Acid etched boded type (15420) Isurace Plas Descriptio of basic restorative services RESTORATION Primary teeth a) Amalgam, o-boded ateriors or posteriors (21101 to 21105) b) Amalgam, boded ateriors or posteriors (21121 to 21125) c) Composite, boded ateriors (23311 to 23315) d) Composite, boded posteriors (23411 to 23415) Permaet teeth a) Amalgam, o-boded ateriors or bicuspids (21211 to 21215) b) Amalgam, o-boded molars (21221 to 21225) c) Amalgam, boded ateriors ad bicuspids (21231 to 21235) d) Amalgam, boded molars (21241 to 21245) e) Composite ateriors (23111 to 23115, 23118) f) Veeer (ateriors ad bicuspids) (23121, 23122) g) Diastema closure, per tooth (23124) h) Composite, boded bicuspids (23210 to 23215) i) Composite, boded molars (23220 to 23225) Retetive pis (amalgam or composite) (21301 to 21304) Supplemet for restoratio of a tooth uder a appliace or supportig a existig removable partial deture: per restoratio (i additio to the code used for retrofillig) (21601) Gold foil (24101, 24102) 27

28 Ilays/olays a) Metal (25100, 25200, 25300, 25500) b) Porcelai, resi or ceramic (25121 to 25123, 25521) Retetive pis for ilays or olays (25601 to 25604) ORAL SURGERY Removal of erupted teeth (ucomplicated) (71101, 71111) Surgical removals a) Erupted teeth (complex) (72100, 72110) b) Impacted tooth (72210, 72220, 72230, 72240) c) Residual roots (72300, 72310, 72320) d) Removal of fragmet(s) of a fractured tooth (72350) e) Surgical exposure of teeth (72410 to 72412) f) Surgical movemet of teeth (72430, 72440) g) Eucleatio of teeth (72450) Supplemet for suturig, per visit: these expeses are oly eligible if claimed together with expeses for removal of erupted teeth (ucomplicated) (71121) Remodellig ad recotourig of oral tissues a) Alveolectomy (73020) b) Alveoloplasty (73100, 73110) c) Stomatoplasty (73123) d) Osteoplasty (73133 to 73135, 73140) e) Tuberoplasty (73150, 73151) f) Removal of hyperplasic tissue (by radiosurgery or dissectio) (73171 to 73176) g) Removal of excess mucosa (by radiosurgery or dissectio) (73181 to 73186) h) Alveolar ridge recostructio with alloplastic material (73360, 73361) i) Extesio of mucous folds with secodary epithelizatio (icludig vestibuloplasty) (73381 to 73384) j) Extesio of mucous folds with mucous or ski graft (73401 to 73404) 28

29 Surgical excisio (cyst ad tumor) a) Removal of tumor (74108, 74109) b) Removal ad curettage of itra-osseous cyst or grauloma (74408 to 74410) Surgical icisio ad draiage (75100, 75101, 75110) Removal of foreig body from the boe or soft tissue (75301, 75361) Freectomy (77801 to 77803) Hemorrhage, cotrol (79400, 79401) Post-surgical treatmet (79601, 79602) Isurace Plas GENERAL ADDITIONAL SERVICES Local aesthesia (04470, 04471) Coscious sedatio by ihalatio (92311 to 92319) Coscious sedatio, itraveous (92331 to 92339) Oral or percutaeous coscious sedatio (92421 to 92429) Professioal visits (94100, 94200, 94400) Descriptio of major restorative services ENDODONTICS Caries/trauma/pai cotrol a) Sedative fillig/idirect cappig (20111, 20121) b) Recotourig ad polishig of traumatized tooth (20131) c) Bodig/cemetatio (20161) Edodotic emergecy a) Pulpotomy (32201, 32202, 32210) b) Ope ad drai through atural tooth (separate emergecy procedure) (39201, 39202) c) Pulpectomy through atural tooth (separate emergecy procedure) (39901 to 39904) d) Relievig traumatic occlusio (39970) e) Reimplatatio of avulsed tooth (39981) f) Repositioig of traumatically displaced tooth (39985) 29

30 Other edodotic services: supplemet for edodotic treatmet through a metal ad/or porcelai crow (32101, 32102) Preparatio of tooth for treatmet (39100, 39110, 39120) Root caal therapy a) Root caal treatmet ad retreatmet i) Oe caal (33100 to 33102, to 33112) ii) Two caals (33200 to 33202, to 33212) iii) Three caals (33300 to 33302, to 33312) iv) Four caals (33400 to 33402, to 33412) v) Additioal caal (33475) b) Apexificatio i) Oe caal (33521, 33531, 33541) ii) Two caals (33522, 33532, 33542) iii) Three caals (33523, 33533, 33543) iv) Four caals or more (33524, 33534, 33544) c) Perforatio repair (34511) Periapical edodotic surgery a) Apicoectomy (as a separate procedure from root caal) (34101 to 34104) b) Apicoectomy ad root caal treatmet performed joitly, with or without retrofillig (34111, 34112, 34114, 34115) c) Apicoectomy ad root caal retreatmet performed joitly, with or without retrofillig (34171, 34172, 34174, 34175) d) Apicoectomy ad retrofillig (as a separate procedure from root caal) (34201 to 34203, 34212, 34215) e) Root amputatio (34401, 34402) f) Itetioal reimplatatio (34451 to 34453) g) Hemisectio (39230) Bleachig of tooth, i office, by a detist: subject to a overall maximum of 10 sessios per caledar year, per isured for all teeth a) No-vital (39410) b) Vital, i office (97101, 97102) 30

31 PERIODONTICS Maagemet of acute ifectios ad other oral lesios (41200) Desesitizatio: up to a overall maximum of 10 applicatios per caledar year, per isured, for all teeth (41300) Periodotal surgery a) Root plaig ad curettage (42000, 42001) b) Gigivoplasty ad/or gigivectomy (42002, 42003, 42010) c) Fibrotomy (42330, 42331) d) Flap approach with osteoplasty ad/or ostoectomy (42100) e) Grafts i) Soft tissue (42200, 42300, 42301, 42560, 42561, 42565) ii) Gigival (42570, 42575) iii) Osseous tissue (42611, 42700, 42711) f) Proximal wedge (mesial or distal) (42400) g) Exploratory surgery, flap approach (42441, 42451) h) Postoperative visit for dressig chage (42720) Adjuctive periodotal procedures a) Temporary splits or ligatios (43200, 43211, 43212, 43260) b) Cast metal split, acid etch boded (43290) c) Removal or recemetatio of split, per tooth (43295) d) Occlusal equilibratio (43300, 43310) e) Periodotal appliaces (to cotrol bruxism) (43611, 43612, 43622, 43631) f) Itraoral appliace for temporomadibular joit (occlusal guard) (43711, 43712, 43732, 43741) g) Periodotal irrigatio, subgigival (49211) h) Itra-sulcular applicatio of slow release atimicrobial ad/or chemotherapeutic agets (49221, 49229) Isurace Plas FIXED PROSTHODONTICS Idividual crows a) Acrylic processed (27100) 31

32 b) Provisioal, acrylic (trasitioal) (27130, 27140, 27150) c) Porcelai, acrylic, ceramic, resi or metal (27200, 27210, 27300, 27310) d) Complemetary services (27401, 27501, 27503, 28211) Other restorative services a) Crow or veeer repair (27721 à 27723) b) Recemetatio ad/or removal (29100, 29200) c) Removal of ilay, olay, o-prefabricated crow or veeer (i additio to preparatio of a ew restoratio), first uit of time ad each additioal uit (29301, 29302) Restrictios cocerig crows Replacemet of idividual crows will be refudable provided satisfactory evidece may establish that the idividual crows may ot be repaired ad, if this crow has bee iserted while this detal care coverage was i force, that at least 4 years have goe by prior to the replacemet. Descriptio of expeses for removable prosthodotics REMOVABLE PROSTHODONTICS Complete detures a) Stadard (51100, 51110, 51120) b) Equilibrated (51201 to 51203) Immediate complete detures (51300, 51310, 51320) Immediate complete detures (trasitioal) (51600, 51610, 51620) Detures, complete, overdeture a) Stadard (51701 to 51703) b) Equilibrated (51711 to 51713) Partial detures, acrylic base (immediate, trasitioal, or permaet) (52101 to 52105, to 52124, 52129, to 52232) Cast partial detures, chrome-cobalt alloy with cast ad/or wrought rests ad clasps (52400, 52410, 52420, 52500, 52510, 52520, to 53133, 53150, to 53223) Complete detures with partial detures (opposig arch), chrome-cobalt, with or without free ed base (52531, 52532, 52542, 52543) 32

33 Removable cast partial detures with precisio attachmets (52600, 52610, 52620) Semi-precisio cast partial detures (52601, 52611, 52630) Hybrid partial detures, cast (52701, 52702) DENTURE ADJUSTMENTS Mior adjustmets, provided that adjustmets are made more tha six moths after the iitial isertio of the deture (54250, 54251) Remout ad equilibratio of complete or partial detures (54300 to 54302) Isurace Plas COMPLETE OR PARTIAL DENTURE REPAIRS Complete deture repairs without impressio (55101 to 55104) Complete deture repairs with impressio (55201 to 55204) Structural additios to partial deture (55520, 55530) Replacemet of teeth i prosthesis (56602) Vertical dimesio recuperatio by additio of acrylic to existig prosthesis (56631) DENTURE CLEANING AND POLISHING (55700) DUPLICATE OF A PROSTHESIS (56100, 56101) REBASING AND RELINING Reliig of complete or partial deture (56200, 56201, 56210, 56211, to 56222, to 56232) Rebase (jump) (56260 to 56263, 56280, 56290) Therapeutic tissue coditioig (56270 to 56273) REMAKE, PARTIAL DENTURES (usig existig framework) (56411 to 56413) Restrictios cocerig removable prosthodotics Ay replacemet of a prosthesis or the additio of teeth to a removable prosthesis is oly eligible for reimbursemet if satisfactory proof is provided that: a) the replacemet or additio of teeth is ecessary followig the extractio of teeth after the iitial deture isertio; or 33

34 b) at least 4 years have elapsed sice the iitial deture isertio. Limitatios to eligible expeses The followig detal procedures are ot eligible for reimbursemet by the Isurer: Detal care provided free of charge or for which the isured does ot have to pay Detal care for which the isured is etitled to reimbursemet uder the Act respectig idustrial accidets ad occupatioal diseases, the Quebec Automobile Isurace Act, or ay other Caadia or foreig law with similar provisios Detal treatmets payable uder ay health isurace pla i which the isured participates 2. Exclusios No beefits are payable for detal care expeses icurred: for a third party for cosmetic surgery, icludig the trasformatio, extractio or replacemet of healthy teeth i order to modify their appearace for ay coditio occurrig while the isured is o active duty with the armed forces 34

35 ACTIVE PARTICIPANT S AND RETIREE S OPTIONAL LIFE INSURANCE PLAN Optio III Isurace Plas Optioal participatio 1. Active participats a) Participat s Basic Life Isurace The amout of Basic Life Isurace payable i the evet of the participat s death is equal to: 1 times the aual salary, rouded to the earest multiple of $5, for participats uder age 65 1 /2 the aual salary, rouded to the earest multiple of $5, for participats age 65 ad over b) Participat s Optioal Life Isurace NOTE: Participatio i this beefit is coditioal o participatio i Basic Life Isurace. Participats may opt for a additioal amout of life isurace equal to their choice of 1 to 5 times their aual salary. This amout is rouded to the earest multiple of $5. This beefit is subject to evidece of isurability i accordace with the Isurer s stadards i force at the time of erolmet ad each time a ew uit of Optioal Life Isurace is added. This beefit does ot apply if the participat dies from suicide or the effects of ay attempted suicide durig the first year followig the effective date of this beefit, its reistatemet or ay icrease i the beefit amout, whether or ot he or she is of soud mid at the time of suicide or attempted suicide. I such case, isurace uder this beefit, or the icrease i isurace, as the case may be, shall be ull ad void, ad the liability of the Isurer shall be limited to a refud of the premiums collected. 35

36 c) Participat s Accidetal Death ad Dismembermet Isurace NOTE: Participatio i this beefit is coditioal o participatio i Basic Life Isurace. If the participat sustais ay of the losses specified below withi 365 days followig the date of a accidet, provided the participat is covered uder this beefit at the time of the accidet, the Isurer will pay the percetage of aual salary idicated below, without exceedig 100% of salary for all losses related to the same accidet. This percetage is reduced by half whe the participat reaches age 65. PERCENTAGE TABLE OF LOSSES OF ANNUAL SALARY Loss of life 100% Loss of both hads or both feet or loss of sight i 100% both eyes Loss of oe had ad oe foot 100% Loss of oe had or oe foot ad the sight i oe eye 100% Loss of oe had or oe foot 50% Loss of sight i oe eye 50% Loss of oe figer 10% The word loss meas, for a had, foot or figer, total ad defiitive loss of use; with respect to eyesight, it meas the total, defiitive ad irrecoverable loss of eyesight. I the evet of a loss sustaied by a disabled perso, the percetage of aual salary remais that established at the oset of disability. For isurace purposes, a disabled perso is deemed to be a retiree as of his or her 65th birthday. This coverage does ot apply if the loss sustaied occurs i the followig cases: While the participat is carryig out ay of the duties of a airplae crew, except as required i the course of his or her duties as stipulated i the collective agreemet or idividual employmet cotract Due to war, whether declared or ot, or participatio i a isurrectio Due to attempted suicide or suicide of the participat, or volutary self harm or ijury, whether or ot the participat is of soud mid Participatio i a crimial act or a act deemed to be crimial, icludig the act of drivig a motor vehicle while havig a blood alcohol level i excess of the prescribed legal limit 36

37 While the participat is o active duty with the armed forces Subsequet to a illess or afflictio that does ot result from a accidet ad becomes apparet at the time of a accidet d) Participat s Spouse s ad Depedet Childre s Life Isurace Isurace Plas NOTE: Participatio i this beefit is coditioal o participatio i Participat s Basic Life Isurace. The beefits payable i the evet of death are equal to: $2,500 for a isured depedet child age 24 hours or older $5,000 for the isured spouse e) Participat s Spouse s Optioal Life Isurace NOTE: Participatio i this beefit is coditioal o participatio i Spouse s ad Depedet Childre s Life Isurace. Participats may choose a additioal amout from 1 to 20 uits of $5,000 o the life of their spouse. This beefit is subject to evidece of isurability i accordace with the Isurer s stadards i force at the time of erolmet ad each time a ew uit of Optioal Life Isurace is added. This beefit does ot apply if the spouse dies from suicide or the effects of ay attempted suicide durig the first year followig the effective date of this beefit, its reistatemet or ay icrease i the beefit amout, whether or ot he or she is of soud mid at the time of suicide or attempted suicide. I such case, isurace uder this beefit, or the icrease i isurace, as the case may be, shall be ull ad void, ad the liability of the Isurer shall be limited to a refud of the premiums collected. 2. Retired participats a) Retiree s Life Isurace Startig o the date of retiremet, participats may cotiue to be isured without evidece of isurability ad choose a amout of up to 20 uits of $5,000, without exceedig the amout held as a active participat, provided they submit a applicatio to the Isurer withi 30 days followig the date of retiremet. 37

38 However, for part-time participats or participats o upaid leave without maitaiig participatio, whose amout of isurace i force immediately prior to retiremet was lower tha $5,000, the amout is deemed to be $5,000. Participats may subsequetly reduce, but caot icrease, the amout of isurace selected. I additio, they may termiate their isurace at ay time, i which case they will o loger be able to participate. Retired participats who retur to work may keep the amout of isurace held as a retiree. I such case, ay ew amout of life isurace for the participat or his or her depedets to which the participat becomes etitled oce he or she retires agai is added to the amout of isurace already held. The total of these amouts therefore forms a sigle amout of isurace for the purposes of applyig the maximums provided uder this beefit (retiree ad depedets). b) Retiree s Spouse s ad Depedet Childre s Life Isurace Retired participats may keep the amout of isurace they held uder the active participat s pla for their spouse ad depedet childre, if applicable, provided they take out Retiree s Life Isurace coverage. Erolmet must occur at the same time for all life isurace plas available to the retiree. The beefits payable i the evet of death are equal to: $2,500 for a isured depedet child age 24 hours or older $5,000 for the isured spouse c) Retiree s Spouse s Optioal Life Isurace Retired participats may keep some or all of the amout of optioal life isurace coverage they held o the life of their spouse uder the active participat s pla, i.e. betwee 1 ad 20 uits of $5,000, provided they take out Retiree s Life Isurace ad Spouse s ad Depedet Childre s Life Isurace coverage. Premium rates are the same as those for the amout of Retiree s Life Isurace coverage, takig the retiree s age ad spouse s geder ito accout. Erolmet must occur at the same time for all life isurace plas available to the retiree. 38

39 3. Accelerated beefit paymet i the evet of termial illess A perso who is isured uder ay of the life isurace plas, whose life expectacy is o more tha 12 moths, may obtai a accelerated beefit paymet by submittig a writte request to the Isurer, accompaied by appropriate medical evidece ad the beeficiary s writte coset. The total amouts paid out (Basic ad Optioal) may ot exceed $50,000 or 25% of the isured s amout of life isurace. All of the provisios regardig the accelerated beefit paymet ca be foud o Page 65 of this booklet. Isurace Plas 39