Dow Chemical Canada, ULC

Transcription

1 Dow Chemical Canada, ULC Divisions 200, 400 and 011 Basic and Optional Plan Group Policy No Group Plan No

2 Dow Chemical Canada, ULC Basic Life Underwritten by: Sun Life Assurance Company of Canada Group Policy No Optional Life Insurance Underwritten by: Sun Life Assurance Company of Canada Group Policy No Extended Health and Dental Administered by: Sun Life Assurance Company of Canada Group Plan No

3 Client Name Table of Contents Policy Number Your Group Benefits Booklet... 1 Overview... 1a General Information... F-1 Section 1. Insured Provisions Summary of Insurance... A-1 Basic and Optional Member Life Insurance Provision... G-1 Basic and Optional Dependant Life Insurance Provision... H-1 Section 2. Administered Services Summary of Benefits BASIC PLAN... B-1 Extended Health Provision (Extended Health Care)... M-1 Extended Health Prescription Drugs (Basic Plan)... N-1 Extended Health Prescription Drugs (Optional Plan)... N-3 Extended Health Hospital Expenses in the Province Where a Person Lives... P-1 Extended Health Medical Services and Equipment, and Paramedical Services (Basic Plan)... Q-1 Extended Health Medical Services and Equipment, and Paramedical Services (Optional Plan)... Q-4 Extended Health Expenses Outside Own Province and Emergency Travel Assistance (Basic and Optional Plan)... Q1-1 Dental Provision (Dental Care)... R-1 Dental Provision - Preventive Benefit (Basic Plan)... S-1 Dental Provision - Basic Benefit (Basic Plan)... S-2 Dental Provision - Major Benefit (Basic Plan)... S-3 Table of Contents i

4 Chapter Group File Your Group Benefits Booklet Keep in a safe place This booklet is a valuable source of information for you and your family. It provides the information you need about the group benefits available through your employer s group plan with Sun Life Assurance Company of Canada (Sun Life), a member of the Sun Life Financial group of companies. Please keep it in a safe place. We also recommend that you familiarize yourself with this information and refer to it when making a claim for group benefits. The contract holder, Dow Chemical Canada, ULC, self-insures the following benefits: Extended Health Dental This means that Dow Chemical Canada, ULC plays a role similar to that of an insurance company for its members. Dow Chemical Canada, ULC has the sole legal and financial liability for the benefits listed above and funds the claims from its net income, retained earnings or other financial resources. Sun Life provides administrative services only (ASO) such as claims processing. All other benefits are insured by Sun Life. The Group Benefits Administration (GBTA) Team at Sun Life is there to help The GBTA Team can: help you enrol in the plan answer any questions you may have Benefits and claims information at your fingertips For more information about your group benefits or claims, please call Sun Life's GBTA Team directly at We're on the Internet! Learn more by surfing Sun Life's website. There's information about group benefits, and about Sun Life's products and services... and a whole lot more! Check us out! Our address is: Accessing your records As required by legislation, for insured benefits, if you reside in Alberta or British Columbia, you may obtain copies of the following documents: your enrolment form or application for insurance. any written statements or other record, not otherwise part of the application, that you provided to Sun Life as evidence of insurability. For insured benefits, on reasonable notice, you may also request a copy of the policy. The first copy will be provided at no cost to you but a fee may be charged for subsequent copies. All requests for copies of documents should be directed to one of the following sources: our Sun Life Financial Plan Member Services website at our Sun Life Financial Customer Care centre by calling toll-free at Your Group Benefits Booklet 1

5 Respecting Your Privacy At Sun Life Financial, protecting your privacy is a priority. We maintain a confidential file in our offices containing personal information about you and your contract(s) with us. Our files are kept for the purpose of providing you with investment and insurance products or services that will help you meet your lifetime financial objectives. Access to your personal information is restricted to those employees, representatives and third party service providers who are responsible for the administration, processing and servicing of your contract(s) with us, our reinsurers or any other person whom you authorize. In some instances these persons may be located outside Canada, and your personal information may be subject to the laws of those foreign jurisdictions. You are entitled to consult the information contained in our file and, if applicable, to have it corrected by sending a written request to us. You have a choice To find out about our Privacy Policy, visit our website at or send a written request by to privacyofficer@sunlife.com, or by mail to Privacy Officer, Sun Life Financial, 225 King St. West, Toronto ON M5V 3C5 to request that a copy of our Privacy Brochure be sent to you. The statements in this booklet are only a summary of some of the provisions in the master policy. If you need further details on the provisions which apply to your group benefits you must refer to the master policy (available from the GBTA Team at Sun Life). Your Group Benefits Booklet 2

6 Overview A MEGlobal Inc. Retired Employees Non QC 11B 11C MEGlobal Inc. Retired Employees QC who have opted into RAMQ MEGlobal Inc. Retired Employees QC who have opted out of RAMQ A Dow Chemical Canada, ULC Retired Employees Non QC 20B 20C Dow Chemical Canada, ULC Retired Employees QC who have opted into RAMQ Dow Chemical Canada, ULC Retired Employees QC who have opted out of RAMQ A Dow AgroSciences Retired Employees Non QC 40B 40C Dow AgroSciences Retired Employees - QC who have opted into RAMQ Dow AgroSciences Retired Employees QC who have opted out of RAMQ Overview 1a

7 F bf03v General Information Eligibility A retired employee is eligible, and continues to be eligible, to be a member while you meet all of the following conditions: 1. You are a member immediately before your date of retirement. 2. You are a resident of Canada. 3. You meet the criteria set up by the plan sponsor. Waiting Period nil You are eligible, and continue to be eligible, for dependant coverage while you meet all of the following conditions: 1. You are a member. 2. You have at least one dependant. 3. Your dependants are residents of Canada. Definitions Dependant means your spouse or a dependent child of you or your spouse. Your dependent must have been covered as your dependent under your employer s group plan on the day proceeding your retirement. Dependent child means a natural, adopted or step-child who is not married or in any other formal union recognized by law, who is entirely dependent on you for maintenance and support and who is 1. under 21 years of age, 2. under 26 years of age and attending a college or university full-time, or 3. physically or mentally incapable of self-support and became incapable to that extent while entirely dependent on you for maintenance and support and while eligible under 1) or 2) above. Earnings relates only to the Provisions described in Section 1 of this booklet and means base salary. Evidence of Insurability and Insurability relates only to the Provisions described in Section 1 of this booklet. He, his and him refer to both genders. Life event change Life event changes include: marriage or any other formal union recognized by law, or common-law, birth or adoption of a child, divorce or legal separation, gain or loss of spouse s benefit coverage, or death of a dependent. Spouse means your spouse by marriage or under any other formal union recognized by law, or a person of the opposite or same sex who is living with and has been living with you in a conjugal relationship for 12 consecutive months. Effective Date Your coverage is effective on the date of your retirement: Your dependant coverage is effective on the date you request dependant coverage. General Information (bf03v) F-1 October 1, 2012 (83140/83141/150028)

8 Changes in Coverage You are eligible to make changes to your benefit choices, during the Enrolment period, as communicated by your Group Benefits Administration team in conjunction with Dow. Changes take effect January 1 st of the following year. You can make changes to your benefit choices within 31 days of a life event change. The changes take effect on the date the request is received, but not before the actual date of the life event change. You may reduce or cancel the amount of Member Optional Life, Spouse Optional Life or Dependent Child Optional Life Insurance, but you cannot increase the coverage. An increase in your benefits or the amount of your coverage or the amount of your dependant coverage due to change in your group benefit plan s design or a change in your classification becomes effective on the date of the change. Termination of Coverage Your coverage could terminate for a number of reasons. For example, you are no longer eligible, the provision or the policy terminates. General Information (bf03v) F-2 October 1, 2012 (83140/83141/150028)

9 A ba00s Section 1. Insured Provisions Summary of Insurance Policy Number Life Insurance (All Classes) Class of Members Benefit Formula Maximum Benefit All Retirees 1x pre retirement annual earnings $1,500,000* Any increase in your annual earnings after you have reached age 65 will not be taken into account when calculating the Benefit Formula. *The maximum benefit available under the combination of Basic Life Insurance (under policy 83140) and Optional Life Insurance (under policy 83141) is $1,500,000. Benefit Reduction: Reduces by 20% on 66th birthday then further reduces by 20% on each following birthday to a minimum of $5,000, for members who retired prior to January 1, 2002 and to a minimum of $10,000, for members who retire on or after January 1, Termination of Insurance: none Policy Number Optional Member Life Insurance (All Classes) Class of Members Benefit Formula Maximum Benefit All Retirees 1x, 2x, 3x, 4x or 5x pre retirement earnings (rounded to the next higher $1000) $1,500,000* *The maximum benefit available under the combination of Basic Life Insurance (under policy 83140) and Optional Life Insurance (under policy 83141) is $1,500,000. Termination of Insurance: 65 th birthday Optional Dependant Life Insurance (All Classes) Class of Dependants Benefit Formula Maximum Benefit Spouse units of $25,000 $300,000 Each Child units of $5,000 $15,000 Termination of Insurance: member s 65 th birthday Summary of Insurance (ba00s) A-1 October 1, 2012 (83140/83141)

10 G bg01v013 Basic and Optional Member Life Insurance Provision Benefit The amount of benefit will be paid to your beneficiary upon your death. If no beneficiary has been appointed or if the beneficiary has predeceased you, payment will be made to your estate. A minor cannot personally receive a death benefit under the plan until reaching the age of majority. If you reside outside Québec and are designating a minor as your beneficiary, you may wish to designate someone to receive the death benefits during the time your beneficiary is a minor. If you reside outside Québec and have not designated a trustee, current legislation may require Sun Life to pay the death benefit to the court or to a guardian or public trustee. If you reside in Québec, the death benefit will be paid to the parent(s)/legal guardian of the minor on the minor s behalf. Alternatively, you may wish to designate the estate as beneficiary and provide a trustee with directions in your will. You are encouraged to consult a legal advisor. Claims A death claim must be received by Sun Life within 6 years of the date of death. The claimant must submit proof of the claim and the right to receive the benefit to Sun Life. Except where or when applicable legislation permits the use of a different limitation period, every action or proceeding against an insurer for the recovery of insurance money payable under the policy is absolutely barred unless commenced within the time set out in the Insurance Act or the time set out in such other legislation as may apply to a claim, action or proceeding for insurance money. Where or when applicable legislation permits the use of a different limitation period, no legal action or proceeding may be brought against Sun Life: 1. regarding any claims for which no payment has been made by Sun Life, more than one year after the end of the time period in which the initial submission of proof of claim is required by the terms of the policy, or 2. regarding claims for which some payment has been made by Sun Life, more than one year after the last payment made by Sun Life with respect to the claim. Exclusion No benefit is payable for any amount of Optional Life Insurance that has been in force for less than 2 years if death is due to suicide while sane or insane. At Termination If your Life Insurance ends for any reason other than your request, you may apply to convert the group Life Insurance to an individual Life policy with Sun Life without providing evidence of insurability. The request must be made within 31 days of the reduction or end of the Life Insurance. There are a number of rules and conditions in the group policy that apply to converting this insurance, including the maximum amount that can be converted. Please contact your employer for details. Basic and Optional Member Life Insurance Provision (bg01v013) G-1 October 1, 2012 (83140/83141)

11 H bh01v009 Basic and Optional Dependant Life Insurance Provision Benefit The amount of benefit will be paid to you upon the death of your insured dependant. Claims A claim must be received by Sun Life within 6 years of the date of death. You must submit proof of claim and the right to receive the benefit to Sun Life. Except where or when applicable legislation permits the use of a different limitation period, every action or proceeding against an insurer for the recovery of insurance money payable under the policy is absolutely barred unless commenced within the time set out in the Insurance Act or the time set out in such other legislation as may apply to a claim, action or proceeding for insurance money. Where or when applicable legislation permits the use of a different limitation period, no legal action or proceeding may be brought against Sun Life: 1. regarding any claims for which no payment has been made by Sun Life, more than one year after the end of the time period in which the initial submission of proof of claim is required by the terms of the policy, or 2. regarding claims for which some payment has been made by Sun Life, more than one year after the last payment made by Sun Life with respect to the claim, or Exclusions No benefit is payable for any amount of Optional Dependant Life Insurance that has been in force for less than 2 years if death is due to suicide, while sane or insane. No benefit is payable for the death of a fetus which, after the complete separation from the mother, shows no sign of life. At Termination If your Dependant Life Insurance for your spouse terminates due to the termination of your Member Life Insurance, your spouse may convert the amount of the dependant insurance terminated to an individual policy on his life. Your spouse must apply and pay the premium to Sun Life within 31 days after termination of insurance. Where necessary in order to comply with applicable legislation: If the dependant insurance for a child terminates due to the termination of your insurance, you may convert the amount of the dependant insurance terminated to an individual policy on the child s life without submitting evidence of insurability. The conditions that apply to the Conversion Privilege for the member's insurance will apply to the Conversion Privilege for the dependant insurance. If your Dependant Life Insurance terminates and the dependant dies within 31 days after termination of insurance, we will pay you the amount of insurance which could have been converted to an individual policy on the dependant life s through the Conversion Privilege of this provision, or the amount stipulated in any applicable legislation, if greater. Basic and Optional Dependant Life Insurance Provision (bh01v009) H-1 October 1, 2012 (83140/83141)

12 B ab000s Section 2. Administered Services Summary of Benefits BASIC PLAN Group Plan: Extended Health (Class A) Part Benefit Deductible per Reimbursement person A Prescription drugs $50* 90%** C Hospital expenses in the none 100% province where a person lives D Medical services and $50* 90%** equipment, and Paramedical services E Expenses outside own province (within Canada) $50* 100% for emergencies 80% for referrals The benefit year is from January 1 to December 31. *The deductible applies per benefit year. The deductible applies to the combined eligible expenses of Parts A, D and E. **When $2,000 of paid expenses have been incurred in a benefit year under Parts A and D by you or your covered dependant, eligible expenses for that individual will be reimbursed at 100% for the remainder of the benefit year. Reimbursement levels Hospital expenses in the province where you or a covered dependant lives: hospital the difference between the cost of a ward and a private hospital room but not more than $150 per day convalescent hospital up to $150 per day. chronic care hospital up to $150 per day. Medical services and equipment, and Paramedical services: private duty nurse maximum of $25,000 for you and for each covered dependant during any 3 consecutive benefit years services of massage therapists, speech therapists, christian science practitioners or acupuncturists up to a maximum of $300 for you and for each covered dependant per benefit year per specialty services of naturopaths up to a maximum of $25 per visit and $300 for you and for each covered dependant per benefit year services of psychologists or social workers up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year services of chiropractors up to a maximum of $25 per visit and $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. services of podiatrists or chiropodists up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. services of osteopaths or osteopathic practitioners up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. services of physiotherapists or occupational therapists up to a combined maximum of $1,000 for you and for each covered dependant per benefit year. Expenses outside own province but within Canada: Expenses incurred for emergency services and referral services within Canada are subject to a combined lifetime maximum of $1,000,000 for you and for each covered dependant or, if lower, any other applicable lifetime maximum. Expenses incurred for referral services within Canada are subject to a lifetime maximum of $500,000 for you and each covered dependant. Summary of Benefits BASIC PLAN (ab000s) B-1

13 Prescription drugs for members and covered dependants who live in Québec The prescription drug deductible ceases to be applied for drugs listed in the Régie de l'assurance-maladie du Québec (RAMQ) drug formulary once the out-of-pocket maximum has been reached. The reimbursement level is increased to 100% once the out-of-pocket maximum for prescription drug expenses has been reached. Québec drug insurance plan Any conditions under this plan that do not meet the requirements under the Québec drug insurance plan are automatically adjusted to meet those requirements. Out-of-pocket maximum Expenses incurred for prescription drugs and not reimbursed under this plan as a result of the application of the deductible or the reimbursement level are limited in each benefit year to the yearly maximum contribution set by the Régie de l'assurance-maladie du Québec (RAMQ). The out-of-pocket maximum applies separately to you and your spouse. Any drug expenses incurred for children are part of the out-of-pocket maximum of the parent with the greater amount of expenses during the benefit year. Maximum benefit $4,000 for you and each covered dependant per benefit year for all expenses combined (excluding hospital, private duty nurse expenses and expenses outside own province) Termination of Coverage: none Extended Health (Class B) Part Benefit Deductible per Reimbursement person A Prescription drugs $50* 90% C Hospital expenses in the none 100% province where a person lives D Medical services and $50* 90%** equipment, and Paramedical services E Expenses outside own province (within Canada) $50* 100% for emergencies 80% for referrals The benefit year is from January 1 to December 31. *The deductible applies per benefit year. The deductible applies to the combined eligible expenses of Parts A, D and E. **When $2,000 of paid expenses have been incurred in a benefit year under Part D by you or your covered dependant, eligible expenses for that individual will be reimbursed at 100% for the remainder of the benefit year. Reimbursement levels Hospital expenses in the province where you or a covered dependant lives: hospital the difference between the cost of a ward and a private hospital room but not more than $150 per day convalescent hospital up to $150 per day. chronic care hospital up to $150 per day. Medical services and equipment, and Paramedical services: private duty nurse maximum of $25,000 for you and for each covered dependant during any 3 consecutive benefit years services of massage therapists, speech therapists, christian science practitioners or acupuncturists up to a maximum of $300 for you and for each covered dependant per benefit year per specialty services of naturopaths up to a maximum of $25 per visit and $300 for you and for each covered dependant per benefit year services of psychologists or social workers up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year services of chiropractors up to a maximum of $25 per visit and $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. services of podiatrists or chiropodists up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. Summary of Benefits BASIC PLAN (ab000s) B-2

14 services of osteopaths or osteopathic practitioners up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. services of physiotherapists or occupational therapists up to a combined maximum of $1,000 for you and for each covered dependant per benefit year. Expenses outside own province but within Canada: Expenses incurred for emergency services and referral services within Canada are subject to a combined lifetime maximum of $1,000,000 for you and for each covered dependant or, if lower, any other applicable lifetime maximum. Expenses incurred for referral services within Canada are subject to a lifetime maximum of $500,000 for you and each covered dependant. Prescription drugs for members and covered dependants who live in Québec The prescription drug deductible ceases to be applied for drugs listed in the Régie de l'assurance-maladie du Québec (RAMQ) drug formulary once the out-of-pocket maximum has been reached. The reimbursement level is increased to 100% once the out-of-pocket maximum for prescription drug expenses has been reached. Québec drug insurance plan Any conditions under this plan that do not meet the requirements under the Québec drug insurance plan are automatically adjusted to meet those requirements. Out-of-pocket maximum Expenses incurred for prescription drugs and not reimbursed under this plan as a result of the application of the deductible or the reimbursement level are limited in each benefit year to the yearly maximum contribution set by the Régie de l'assurance-maladie du Québec (RAMQ). The out-of-pocket maximum applies separately to you and your spouse. Any drug expenses incurred for children are part of the out-of-pocket maximum of the parent with the greater amount of expenses during the benefit year. Maximum benefit $4,000 for you and each covered dependant per benefit year for all expenses combined (excluding hospital, private duty nurse expenses and expenses outside own province) Termination of Coverage: none Extended Health (Class C) Part Benefit Deductible per Reimbursement person A Prescription drugs $50* 90% C Hospital expenses in the none 100% province where a person lives D Medical services and $50* 90%** equipment, and Paramedical services E Expenses outside own province (within Canada) $50* 100% for emergencies 80% for referrals The benefit year is from January 1 to December 31. *The deductible applies per benefit year. The deductible applies to the combined eligible expenses of Parts A, D and E. **When $2,000 of paid expenses have been incurred in a benefit year under Part D by you or your covered dependant, eligible expenses for that individual will be reimbursed at 100% for the remainder of the benefit year. Reimbursement levels Hospital expenses in the province where you or a covered dependant lives: hospital the difference between the cost of a ward and a private hospital room but not more than $150 per day convalescent hospital up to $150 per day. chronic care hospital up to $150 per day. Summary of Benefits BASIC PLAN (ab000s) B-3

15 Medical services and equipment, and Paramedical services: private duty nurse maximum of $25,000 for you and for each covered dependant during any 3 consecutive benefit years services of massage therapists, speech therapists, christian science practitioners or acupuncturists up to a maximum of $300 for you and for each covered dependant per benefit year per specialty services of naturopaths up to a maximum of $25 per visit and $300 for you and for each covered dependant per benefit year services of psychologists or social workers up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year services of chiropractors up to a maximum of $25 per visit and $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. services of podiatrists or chiropodists up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. services of osteopaths or osteopathic practitioners up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. services of physiotherapists or occupational therapists up to a combined maximum of $1,000 for you and for each covered dependant per benefit year. Expenses outside own province but within Canada: Expenses incurred for emergency services outside Canada and referral services within Canada are subject to a combined lifetime maximum of $1,000,000 for you and for each covered dependant or, if lower, any other applicable lifetime maximum. Expenses incurred for referral services within Canada are subject to a lifetime maximum of $500,000 for you and each covered dependant. Prescription drugs for members and covered dependants who live in Québec The prescription drug deductible ceases to be applied for drugs listed in the Régie de l'assurance-maladie du Québec (RAMQ) drug formulary once the out-of-pocket maximum has been reached. The reimbursement level is increased to 100% once the out-of-pocket maximum for prescription drug expenses has been reached. Québec drug insurance plan Any conditions under this plan that do not meet the requirements under the Québec drug insurance plan are automatically adjusted to meet those requirements. Out-of-pocket maximum Expenses incurred for prescription drugs and not reimbursed under this plan as a result of the application of the deductible or the reimbursement level are limited in each benefit year to the yearly maximum contribution set by the Régie de l'assurance-maladie du Québec (RAMQ). The out-of-pocket maximum applies separately to you and your spouse. Any drug expenses incurred for children are part of the out-of-pocket maximum of the parent with the greater amount of expenses during the benefit year. Maximum benefit $4,000 for you and each covered dependant per benefit year for all expenses combined (excluding hospital, private duty nurse expenses and expenses outside own province). Coverage for prescription drugs continues after the maximum benefit has been reached. Termination of Coverage: none Summary of Benefits BASIC PLAN (ab000s) B-4

16 Summary of Benefits OPTIONAL PLAN Group Plan No.: Optional Extended Health (Classes A and C) Part Benefit Deductible per Reimbursement person A Prescription drugs $25* 100% C Hospital expenses in the none 100% province where a person lives D Medical services and $25* 100%** equipment, and Paramedical services E Expenses outside own province (within Canada) $25* 100% for emergencies 80% for referrals The benefit year is from January 1 to December 31. *The deductible applies per benefit year. The deductible applies to the combined eligible expenses of Parts A, D and E. **Insulin pumps are reimbursed at 80%. Blood glucose monitors are reimbursed at 90%. Reimbursement levels Hospital expenses in the province where you or a covered dependant lives: hospital the difference between the cost of a ward and a private hospital room, but not more than $200 per day convalescent hospital up to $200 per day chronic care hospital up to $200 per day Medical services and equipment, and Paramedical services: private duty nurse maximum of $25,000 for you and for each covered dependant during any 3 consecutive benefit years services of massage therapists, speech therapists, christian science practitioners or acupuncturists up to a maximum of $300 for you and for each covered dependant per benefit year per specialty services of naturopaths up to a maximum of $25 per visit and $300 for you and for each covered dependant per benefit year services of psychologists or social workers up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year services of chiropractors up to a maximum of $25 per visit and $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. services of podiatrists or chiropodists up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. services of osteopaths or osteopathic practitioners up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. services of physiotherapists or occupational therapists unlimited. Expenses outside own province but within Canada: Expenses incurred for emergency services, and referral services within Canada are subject to a combined lifetime maximum of $1,000,000 for you and for each covered dependant or, if lower, any other applicable lifetime maximum. Prescription drugs for members and covered dependants who live in Québec The prescription drug deductible ceases to be applied for drugs listed in the Régie de l'assurance-maladie du Québec (RAMQ) drug formulary once the out-of-pocket maximum has been reached. Summary of Benefits BASIC PLAN (ab000s) B-5

17 The reimbursement level is increased to 100% once the out-of-pocket maximum for prescription drug expenses has been reached. Québec drug insurance plan Any conditions under this plan that do not meet the requirements under the Québec drug insurance plan are automatically adjusted to meet those requirements. Out-of-pocket maximum Expenses incurred for prescription drugs and not reimbursed under this plan as a result of the application of the deductible or the reimbursement level are limited in each benefit year to the yearly maximum contribution set by the Régie de l'assurance-maladie du Québec (RAMQ). The out-of-pocket maximum applies separately to you and your spouse. Any drug expenses incurred for children are part of the out-of-pocket maximum of the parent with the greater amount of expenses during the benefit year. Maximum benefit $5,000 for you and for each covered dependant per benefit year for all expenses combined (excluding hospital, private duty nurse, insulin pumps, extremity pumps and expenses outside own province). Termination of Coverage: none Optional Extended Health (Class B) Part Benefit Deductible per Reimbursement person A Prescription drugs $25* 100% C Hospital expenses in the none 100% province where a person lives D Medical services and $25* 100%** equipment, and Paramedical services E Expenses outside own province (within Canada) $25* 100% for emergencies 80% for referrals The benefit year is from January 1 to December 31. *The deductible applies per benefit year. The deductible applies to the combined eligible expenses of Parts A, D and E. **Insulin pumps are reimbursed at 80%. Blood glucose monitors are reimbursed at 90%. Reimbursement levels Hospital expenses in the province where you or a covered dependant lives: hospital the difference between the cost of a ward and a private hospital room, but not more than $200 per day convalescent hospital up to $200 per day chronic care hospital up to $200 per day Medical services and equipment, and Paramedical services: private duty nurse maximum of $25,000 for you and for each covered dependant during any 3 consecutive benefit years services of massage therapists, speech therapists, christian science practitioners or acupuncturists up to a maximum of $300 for you and for each covered dependant per benefit year per specialty services of naturopaths up to a maximum of $25 per visit and $300 for you and for each covered dependant per benefit year services of psychologists or social workers up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year services of chiropractors up to a maximum of $25 per visit and $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. services of podiatrists or chiropodists up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. services of osteopaths or osteopathic practitioners up to a maximum of $25 per visit and a combined maximum of $300 for you and for each covered dependant per benefit year. The cost of x-ray examinations is not included in the benefit year maximum. services of physiotherapists or occupational therapists unlimited. Summary of Benefits BASIC PLAN (ab000s) B-6

18 Expenses outside own province but within Canada: Expenses incurred for emergency services, and referral services within Canada are subject to a combined lifetime maximum of $1,000,000 for you and for each covered dependant or, if lower, any other applicable lifetime maximum. Prescription drugs for members and covered dependants who live in Québec The prescription drug deductible ceases to be applied for drugs listed in the Régie de l'assurance-maladie du Québec (RAMQ) drug formulary once the out-of-pocket maximum has been reached. The reimbursement level is increased to 100% once the out-of-pocket maximum for prescription drug expenses has been reached. Québec drug insurance plan Any conditions under this plan that do not meet the requirements under the Québec drug insurance plan are automatically adjusted to meet those requirements. Out-of-pocket maximum Expenses incurred for prescription drugs and not reimbursed under this plan as a result of the application of the deductible or the reimbursement level are limited in each benefit year to the yearly maximum contribution set by the Régie de l'assurance-maladie du Québec (RAMQ). The out-of-pocket maximum applies separately to you and your spouse. Any drug expenses incurred for children are part of the out-of-pocket maximum of the parent with the greater amount of expenses during the benefit year. Maximum benefit $5,000 for you and for each covered dependant per benefit year for all expenses combined (excluding hospital, private duty nurse, insulin pumps, extremity pumps and expenses outside own province). Termination of Coverage: none Dental (Classes A, B and C) Part Benefit Deductible per family Reimbursement Maximum unit A Preventive none 80%*** $1,000* B Basic none 50%**** * C Major none 50% Crowns - $250** Dentures - $500** Bridges - $800** The benefit year is from January 1 to December 31. *The maximum amount payable applies to the combined eligible expenses incurred in a benefit year under Parts A and B for you and for each covered dependant. **The maximum amount payable applies to the eligible expenses incurred in a benefit year under Part C for you and for each covered dependant. ***Space maintainers are reimbursed at 50%. ****Fillings and extractions are reimbursed at 80% Dental Fee Guide: The applicable fee guide is the Dental Association Fee Guide for general practitioners in the province where you live which was current two years prior to the date the eligible expenses were incurred, regardless of where the treatment is received. If services are provided by a board qualified specialist in endodontics, prosthodontics, oral surgery, periodontics, paedodontics or orthodontics whose dental practice is limited to that speciality, then the fee guide approved by the provincial Dental Association for that specialist will be used. When a fee guide is not published for a given year, the term fee guide may also mean an adjusted fee guide established by Sun Life. Termination of Coverage: none Summary of Benefits BASIC PLAN (ab000s) B-7

19 M amehcvsl Extended Health Provision (Extended Health Care) Benefit In this section, you means the member and all dependants covered for the Extended Health Benefit. Extended Health pays for eligible services or supplies for you that are medically necessary for the treatment of an illness. Medically necessary means generally recognized by the Canadian medical profession as effective, appropriate and required in the treatment of an illness in accordance with Canadian medical standards. To qualify for this coverage you must be entitled to benefits under a provincial medicare plan or a federal government plan or Inpatriate Health Plan approved by Sun Life. Sun Life will reimburse you when Sun Life receives proof that you have incurred any of the eligible expenses for medically necessary services required for the treatment of disease or injury. Eligible expenses for the services of a practitioner include only those services which are performed within his area of expertise and require the skills and qualifications of such a practitioner. Sun Life will pay for eligible expenses taking into account all limitations and the Co-ordination of benefits provision. An eligible expense is allocated to the benefit year in which it is incurred. The benefit year is specified in the Summary of Benefits An eligible expense is incurred on the date the services are received or on the date supplies are purchased or rented. To determine the amount payable, the total eligible expenses claimed are adjusted as follows: the deductible, which must be satisfied each benefit year, is subtracted, the reimbursement percentage is applied, and the eligible expense maximums specified in the Summary of Benefits and this section are applied. The intentional omission, misrepresentation or falsification of information relating to any claim constitutes fraud. Co-ordination of Benefits If you or your dependants are covered under this plan and another plan, Sun Life will co-ordinate benefits under this plan with the other plan following insurance industry standards. These standards determine which plan you should claim from first. The plan that does not contain a co-ordination of benefits clause is considered to be the first payer and therefore pays benefits before a plan which includes a co-ordination of benefits clause. For dental accidents, health plans with dental accident coverage pay benefits before dental plans. Following payment under another plan, the amount of benefit payable under this plan will not exceed the total amount of eligible expenses incurred less the amount paid by the other plan. Where both plans contain a co-ordination of benefits clause, claims must be submitted in the order described below. Claims for you and your spouse should be submitted in the following order: 1. the plan where the person is covered as an employee. If the person is an employee under two plans, the following order applies: the plan where the person is covered as an active full-time employee, the plan where the person is covered as an active part-time employee, the plan where the person is covered as a retiree. 2. the plan where the person is covered as a dependant. Extended Health Provision (Extended Health Care) (amehcvsl) M-1

20 Claims for a dependent child should be submitted in the following order: 1. the plan where the dependent child is covered as an employee, 2. the plan where the dependent child is covered under a student health or dental plan provided through an educational institution, 3. the plan of the parent with the earlier birth date (month and day) in the calendar year, 4. the plan of the parent whose first name begins with the earlier letter in the alphabet, if the parents have the same birthdate. The above order applies in all situations except when parents are separated/divorced and there is no joint custody of the dependent child, in which case the following order applies: 1. the plan of the parent with custody of the dependent child, 2. the plan of the spouse of the parent with custody of the dependent child, 3. the plan of the parent not having custody of the dependent child, 4. the plan of the spouse of the parent not having custody of the dependent child. When you submit a claim, you have an obligation to disclose to Sun Life all other equivalent coverage that you or your dependants have. Claims To make a claim, complete the claim form that is available from Sun Life s Plan Member Services website, or contact GBTA. In order for you to receive benefits, Sun Life must receive the claim no later than the earlier of: 730 days following the date during which the expense is incurred, or 90 days following the end of your Extended Health Coverage. For the assessment of a claim, Sun Life may require itemized bills, attending physician statements or other information Sun Life considers necessary. There is a time limit for proceedings against Sun Life for payment of a claim. A proceeding must be started within 1 year of Sun Life's receipt of the proof of claim. Sun Life has the right to recover all overpayments of benefits either by deducting from other benefits or by any other available legal means. Exclusions and Limitations Sun Life will not pay for the costs of: services or supplies payable or available (regardless of any waiting list) under any government-sponsored plan or program, except as described below under Integration with Government Programs. services or supplies to the extent that their costs exceed the reasonable and usual rates in the locality where the services or supplies are provided. equipment that Sun Life considers ineligible (examples of this equipment are orthopaedic mattresses, exercise equipment, air-conditioning or air-purifying equipment, whirlpools and humidifiers). any services or supplies that are not usually provided to treat an illness, including experimental or investigational treatments. Experimental or investigational treatments mean treatments that are not approved by Health Canada or other government regulatory body for the general public. services or supplies that do not qualify as medical expenses under the Income Tax Act (Canada). services or supplies for which no charge would have been made in the absence of this coverage. expenses for services and products, rendered or prescribed by a person who is ordinarily a resident in the patient s home or who is related to the patient by blood or marriage. Extended Health Provision (Extended Health Care) (amehcvsl) M-2

21 Sun Life will not pay benefits when the claim is for an illness resulting from: the hostile action of any armed forces, insurrection or participation in a riot or civil commotion. any work for which you were compensated that was not done for the employer who is providing this plan. participation in a criminal offence. Integration with Government Programs This plan will integrate with benefits payable or available under the government-sponsored plan or program (the government program). The covered expense under this plan is that portion of the expense that is not payable or available under the government program, regardless of: whether you have made an application to the government program, whether coverage under this plan affects your eligibility or entitlement to any benefits under the government program, or any waiting lists. At Termination If the Extended Health benefit terminates, coverage for dental services to repair natural teeth damaged by an accidental blow will continue, if the accident occurred while you were covered, and the procedure is performed within 6 months after the date of the accident. If you die, your surviving spouse on the plan will be offered the opportunity to enrol for Basic Extended Health coverage for themselves and your surviving dependent children. They will be contacted by the GBTA team. My Health CHOICE Coverage If your coverage under this plan terminates because your employment has ended, you may purchase Sun Life's My Health CHOICE coverage. This coverage is different from your group plan. To be eligible for My Health CHOICE coverage, you must: apply for My Health CHOICE coverage within 60 days after the termination of your coverage, be under age 75 on the date you apply, and be a resident of Canada and be covered under the provincial health plan. My Health CHOICE coverage may also include Dental coverage if you were covered for both Extended Health Care and Dental Care benefits under this group plan, and both benefits terminated. You may cover your spouse and dependents if those family members were covered under your group plan. Your spouse must be under age 75 on the date you apply for this coverage. From time to time, Sun Life may review the eligibility requirements and, on the date you apply for My Health CHOICE coverage, they may be different from those listed in this booklet. To apply for My Health CHOICE or if you have any questions, please call Sun Life s Customer Solutions Centre at Extended Health Provision (Extended Health Care) (amehcvsl) M-3

22 N anpdd84vsl Extended Health Prescription Drugs (Basic Plan) Definitions Dentist means a person licensed to practise dentistry by the provincial licensing authority. Eligible Expenses Sun Life will pay for the cost of the following drugs and supplies that are prescribed by a doctor or dentist and are obtained from a pharmacist. Drugs covered under this plan must have a Drug Identification Number (DIN) in order to be eligible. drugs that legally require a prescription. life-sustaining drugs that may not legally require a prescription. injectable drugs and vitamins. compounded preparations, provided that the principal active ingredient is an eligible expense and has a DIN. diabetic supplies. products to help you quit smoking that legally require a prescription. vaccines. colostomy supplies. varicose vein injections. Payments for any single purchase are limited to the cost of a supply that can reasonably be used in a 3 month period. Sun Life will reimburse certain drugs prescribed by other qualified health professionals the same way as if the drugs were prescribed by a doctor or a dentist if the applicable provincial legislation permits them to prescribe those drugs. Exclusions and Limitations Sun Life will not pay for the following, even when prescribed: intrauterine devices (IUDs) and diaphragms. drugs for the treatment of infertility. infant formulas (milk and milk substitutes), minerals, proteins, vitamins and collagen treatments. the cost of giving injections, serums and vaccines. treatments for weight loss, including drugs, proteins and food or dietary supplements. hair growth stimulants. drugs for the treatment of sexual dysfunction. drugs that are used for cosmetic purposes. natural health products, whether or not they have a Natural Product Number (NPN). drugs and treatments, and any services and supplies relating to the administration of the drug and treatment, administered in a hospital, on an in-patient or out-patient basis, or in a government-funded clinic or treatment facility. expenses incurred under any of the conditions listed on the Extended Health Insurance Provision page as an Exclusion or Limitation. Extended Health Prescription Drugs (Basic Plan) (anpdd84vsl) N-1