Turning 65? NB Drug Plans. Medavie Blue Cross Seniors Health Program. you can receive drug and health coverage. January 2018.

Transcription

1 Turning 65? you can receive drug and health coverage NB Drug Plan & Medavie Blue Cro Senior Health Program MISC-425B 01/18 e n i o r health program January 2018

2 Getting Started Getting Started You are receiving thi package becaue you are turning 65 and you now have more option available for health and drug coverage. Thi package detail different way you can receive precription drug coverage. You can alo add hopital coverage and chooe between two health benefit plan. Read through the different plan to determine the coverage that i bet for you. In the centre of thi package you will find application form and return envelope to ign up for the coverage you want. Who i eligible? New Brunwick enior are eligible to apply for drug coverage if they: are 65 year of age or older; are a permanent reident of New Brunwick; have a valid NB Medicare Card, and do not have precription drug coverage from another plan. Privacy The Government of New Brunwick i committed to afeguarding your privacy. Viit our privacy web page ( for more information on our privacy practice and your right regarding thi iue. Medavie Blue Cro i committed to afeguarding your privacy. Viit our privacy web page (medaviebc.ca/legal/privacy) for more information on our privacy practice and your right regarding thi iue.

3 Available Coverage Precription Drug Coverage New Brunwick Precription Drug Program... page 2 New Brunwick Drug Plan.... page 3 Medavie Blue Cro Senior Health Program....page 4 Additional Coverage Available Coverage Hopital Benefit... page 5 Baic & Enhanced Health Benefit... page 5 Comparion Chart... page 6 Quetion & Anwer Frequently Aked Quetion... page 7 & 8 Form Form along with correponding reply envelope... centrefold 1

4 New Brunwick Precription Drug Program 2 New Brunwick Precription Drug Program You qualify for the New Brunwick Precription Drug Program if you receive the federal Guaranteed Income Supplement (GIS) from Employment and Social Development Canada. Each enior (65 year of age or older) in a family applie for the Precription Drug Program individually. Annual Premium None To enrol in thi program: Complete the Guaranteed Income Supplement Confirmation Form Mail or fax u your form For more information, viit our webite: Co-pay per Precription $9.05 up to an annual co-pay ceiling of $500 per peron confirmation form: Guaranteed Income Supplement Confirmation Form Telephone: Fax: info@nbdrug-medicamentnb.ca ( i not intended to end confidential information) If you do not receive the Guaranteed Income Supplement, pleae contact u if you are: a ingle peron (65 year of age or older) with an annual income of $17,198 or le a couple (with both peron 65 year of age or older) with an annual income of $26,955 or le a couple (with one peron 65 year of age or older, and the other peron under 65 year of age) with an annual income of $32,390 or le

5 New Brunwick Drug Plan Uninured New Brunwicker, including enior, may enrol in the New Brunwick Drug Plan. Member in thi plan pay a premium and a 30 % copayment, up to a maximum amount per precription. Premium and copayment are baed on income. Gro Income Level Premium Co-pay Individual with 30% Co-pay children / Couple Monthly to a Maximum Individual with or without Premium per children (per adult) Precription NB Drug Plan $17,884 or le $26,826 or le $16.67 $5 $17,885 to $22,346 $26,827 to $33,519 $33.33 $10 $22,347 to $26,360 $33,520 to $49,389 $66.67 $15 $26,361 to $50,000 $49,390 to $75,000 $ $20 $50,001 to $75,000 $75,001 to $100,000 $ $25 Over $75,000 Over $100,000 $ $30 To enrol in thi plan: Complete the New Brunwick Drug Plan Application Form Mail or fax u your form For more information, viit our webite: application form: New Brunwick Drug Plan Application for Coverage Telephone: Fax: info@nbdrug-medicamentnb.ca ( i not intended to end confidential information) 3

6 Medavie Blue Cro Senior Precription Drug Program 4 Medavie Blue Cro Senior Precription Drug Program Uninured New Brunwicker (65 year of age or older) may enrol in the Medavie Blue Cro Senior Precription Drug Program. Monthly Premium When hould I apply for the Medavie Blue Cro Senior Precription Drug Program? Knowing when you hould apply i very important. You will be accepted into the Medavie Blue Cro Senior Precription Drug Program if: you apply within 60 day following your 65th birthday, or you are older than age 65 and you apply within 60 day following the cancellation of a previou precription drug plan, or you are older than age 65 and you apply within 60 day following gaining eligibility for NB Medicare a a new reident. Mied the date or forgot to apply within the 60-day limit? If you did not apply within the 60-day limit, you may apply a a late applicant but are required to complete a medical quetionnaire. You may or may NOT be accepted, baed on your medical hitory. To begin thi proce, call toll free To enrol in thi program: Complete the Medavie Blue Cro Senior Precription Drug Program Application Form Mail, or fax u your form application form: Medavie Blue Cro Senior Precription Drug Program Application Form Telephone: Fax: info@nbdrug-medicamentnb.ca Co-Pay per Precription $115 $15 TM The Blue Cro ymbol and name are regitered trademark of the Canadian Aociation of Blue Cro Plan, ued under licence by Medavie Blue Cro, an independent licenee of the Canadian Aociation of Blue Cro Plan. *Trade-mark of the Canadian Aociation of Blue Cro Plan. Trade-mark of Blue Cro Blue Shield Aociation.

7 Hopital and Health Benefit All the previou plan cover precription drug only. To complement your drug coverage, conider adding hopital coverage and health benefit to deign a plan to bet uit your need. Hopital Benefit View the Comparion Chart on page 6, to ee which benefit are right for you. *Late Applicant Proviion: There i a one year waiting period for certain benefit under Health Benefit (Baic and Enhanced) if you do not apply within 60 day following your 65th birthday, or within 60 day following the termination date of other health benefit, or within 60 day of obtaining NB Medicare a a new reident. What if I want more coverage? Medavie Blue Cro offer a wide range of benefit that may meet your need including health, dental, travel and life inurance. Dental benefit are covered at 70% and include: recall exam, polihing, caling, filling, root canal treatment, extraction, minor denture repair, denture reline and rebae. Frequency limit may apply. Thi plan doe not provide dental coverage for the firt ix month following enrolment. To dicu further, call toll free To add hopital, health or dental benefit: Complete the Medavie Blue Cro Senior Health Program Application Form Mail, or fax u your form e n i o r health program $31.50 per month Hopital benefit cover 80% up to $50 per day up to a maximum of 90 day per year toward a emi-private or private hopital room. Thi plan doe not provide hopitalization coverage for the firt three month following enrolment. Baic Health Benefit Enhanced Health Benefit Individual Dental Benefit $10 per month $20 per month $34.74 per month (billed eparately) application form: Medavie Blue Cro Senior Health Program Application Form Telephone: Fax: individual.ale@medavie.bluecro.ca Additional Coverage Medavie Blue Cro Senior Health Program 5

8 Additional Coverage Medavie Blue Cro Senior Health Program 6 Health Benefit Comparion Chart Health Benefit Diabetic Tet Strip and Lancet* Diabetic Needle and Syringe* Gradient Preure Support Hearing Aid* Brace, Splint, Orthotic Cutom-made Ankle Foot Brace Otomy Supplie* Prothetic Limb* Breat Prothei* Hair Prothei* Tracheotomy Supplie Viion Care* X-ray Health Practitioner Chiropractor Podiatrit Pychologit Maage Therapit Oteopath Phyiotherapit Speech Therapit Repiratory Device Incontinent/Catheter Product Accidental Dental Ambulance Emergency Drug out of Province but within Canada Equipment Rental* Nuring Oxygen Equipment* Oxygen* Blood Glucoe Monitor* Orthopedic Shoe and Supplie Eye Prothei* Contact lene due to dieae* Baic Health Benefit 80% $320 per year $180 per year 2 per year $320 every 5 year $200 per year $300 per year Covered Maximum and frequency limit apply $160 every 2 year $240 per lifetime Covered $64 every 2 year $20 combined with Chiropractor maximum $12 per viit up to $100 per year combined with X-ray $16 per viit up to 5 viit per year Benefit not covered. * Late applicant proviion (ee page 5) Enhanced Health Benefit 80% $320 per year $180 per year 2 per year $320 every 5 year $400 per year $400 per year Covered Maximum and frequency limit apply $160 every 2 year $240 per lifetime Covered $100 every 2 year $20 per year combined with health practitioner maximum $200 per year per health practitioner up to a combined maximum of $400 per year $400 every 3 year Covered $7,000 per lifetime $400 per year Covered Covered $250 per year $1,600 every 3 year $1,200 per year $80 every 5 year $100 per year $300 every 3 year $200 every 2 year

9 Frequently Aked Quetion Which drug are covered? To view the lit of drug eligible under the New Brunwick Drug Plan, viit and follow the link entitled New Brunwick Drug Plan Formulary. To view the lit of drug eligible under the New Brunwick Precription Drug Program and the Medavie Blue Cro Senior Precription Drug Program, viit and follow the link entitled Formulary. Mot drug lited are regular benefit that are reimbured with no criteria or prior approval requirement. Some drug require pecial authorization and have pecific criteria that mut be met in order to be reimbured. Do the drug plan cover more than precription drug? No, the drug plan cover precription drug only. If you deire coverage for additional benefit including viion care, hearing aid, nuring, oxygen, diabetic upplie and medical equipment, you can purchae health benefit through the Medavie Blue Cro Senior Health Program. Call toll free at Frequently Aked Quetion Can my poue alo be covered if he/he i under 65 year of age? Ye, if your poue i uninured, he/he can apply for drug coverage under the New Brunwick Drug Plan or with Medavie Blue Cro. Can my poue and I be covered under different plan? Ye, you and your poue may be covered under different plan preented in thi document, depending on your ituation. 7

10 Frequently Aked Quetion Frequently Aked Quetion How do I qualify for drug coverage if I am moving to New Brunwick? The firt tep i to apply for New Brunwick Medicare coverage. When you receive your Medicare card, check the date that your Medicare coverage become effective. Then call the telephone number correponding to the coverage you wih to apply for. To guarantee your acceptance for the Medavie Blue Cro Senior Precription Drug Program, you mut apply within 60 day of your Medicare effective date. If you do NOT apply within 60 day following your Medicare effective date, you will be conidered a late applicant and may or may NOT be accepted, baed on your medical hitory. If I m moving outide New Brunwick, can I till get my drug covered? All the drug plan are for New Brunwick reident only. If you are planning to move outide New Brunwick, you mut advie Medicare and your drug plan of your moving date and your coverage will be cancelled accordingly. Although you can t take your drug plan with you, for mot drug you can obtain a 90-day upply of your medication before leaving New Brunwick, to cover the period until you can obtain coverage in your new province of reidence. You hould find out a oon a poible what your coverage option are in your new home province. 8

11 New Brunwick Precription Drug Program Precription Drug Program P.O. Box 690 Moncton NB E1C 8M7 Telephone: Toll Free: Fax: Toll Free Fax: How to complete thi form Guaranteed Income Supplement Confirmation Form 1. If you are receiving the Guaranteed Income Supplement (GIS), pleae complete all ection. Pleae print clearly. Incomplete information may delay proceing. If you have any quetion, pleae call u at the number above. 2. Mail or fax your completed and igned form along with the required documentation that confirm you are receiving the GIS (ee below for detail) to the addre/fax number above. 3. Once thi form i proceed, you will receive a letter confirming if you qualify. The copayment for thi plan i $9.05 per precription, to a maximum of $ annually. Who i eligible to apply New Brunwick reident with a valid Medicare card, who are 65 year old or older, and who receive the federal Guaranteed Income Supplement are eligible for the New Brunwick Precription Drug Program (NBPDP). Section 1 - Peronal information (required) Name of Applicant: Social Inurance Number: Date of Birth: DD / MM / YYYY Medicare Number: Addre: Potal Code: Telephone Number: Gender: q Male q Female Language of Preference: q Englih q French Have you had drug coverage through another health inurance plan within the lat 12 month? q Ye q No If Ye, when did thi coverage end or will be ending? DD / MM / YYYY Section 2 - Documentation (required) Pleae encloe the following document with thi form. q A letter from Service Canada that indicate the month the GIS wa added to your Old Age Penion. You can obtain thi letter by calling toll-free FORM-892E 01/18 CONTINUED ON REVERSE Adminitered by Medavie Blue Cro on behalf of the Government of New Brunwick

12 Section 3 - Conent to releae Guaranteed Income Supplement information (required) I hereby conent to the releae, by Employment and Social Development Canada to an official of the New Brunwick Department of Health and/or it Delivery Agent, of information about my eligibility and entitlement for the Guaranteed Income Supplement, and, if applicable, other required adminitrative information about me, whether upplied by me or by a third party. The information will be relevant to, and ued olely for the purpoe of, determining and verifying my eligibility for benefit under the New Brunwick Precription Drug Program, and will not be dicloed to any other peron or organization without my approval. I undertand that, if I wih to withdraw thi authorization, I may do o at any time by writing to the New Brunwick Precription Drug Program. Thi authorization i valid for the current year and each ubequent conecutive year for which benefit under the New Brunwick Precription Drug Program may be requeted and determined. Name of Applicant: Signature: Date Signed: DD / MM / YYYY Section 4 - Peronal declaration and authorization (required) By igning thi confirmation form, I confirm that: I am applying to become a member of the New Brunwick Precription Drug Program and I am providing information on thi form for thi purpoe. I undertand that I can withdraw my application and cancel my memberhip at any time. The information provided on thi form i true to the bet of my knowledge. I undertand that knowingly providing fale or incomplete information i an offence. I authorize the New Brunwick Precription Drug Program to collect my Social Inurance Number, a well a information from Medicare and other ource to verify the information on thi form and to verify eligibility for the New Brunwick Precription Drug Program. I agree to notify the New Brunwick Precription Drug Program immediately of any change that may affect my coverage. I undertand that the peronal information I provide, a well a any other peronal information currently held or collected in the future, may be collected, ued or dicloed to adminiter the New Brunwick Precription Drug Program. I authorize the New Brunwick Precription Drug Program to collect, ue and dicloe my peronal information a decribed above for a long a I remain a member of the New Brunwick Precription Drug Program. I undertand that I can revoke my conent at any time. In ome intance, revoking my conent may prevent the New Brunwick Precription Drug Program from providing me with the requeted coverage or benefit. Name of Applicant: Signature: Date Signed: DD / MM / YYYY Thi information i collected under the authority of the Precription Drug Payment Act, SNB 1975, c P-15.01, 2. Thi information will be ued and dicloed to adminiter the New Brunwick Precription Drug Program. It may be ued and dicloed in accordance with the Peronal Health Information Privacy and Acce Act, SNB 2009, c P For more information regarding collection and ue of peronal information, viit or contact the New Brunwick Precription Drug Program at the addre or telephone number hown on page 1 of thi application. Adminitered by Medavie Blue Cro on behalf of the Government of New Brunwick

13 NB Drug Plan How to complete your application Application for Coverage Prior to applying, pleae contact the New Brunwick Drug Plan Inquiry Line at to confirm that the drug you would like covered i included in the New Brunwick Drug Plan Formulary. 1. Complete all ection - pleae print clearly. Enure both you and your poue ign ection 3 and Only one application form per family i neceary. If you have a poue and/or dependant(), they do not need to complete a eparate application. 3. If you are applying for coverage and have an exiting drug plan, you mut complete the Exiting Drug Coverage form, and end it along with your completed application form. The Exiting Drug Coverage form i available on the New Brunwick Drug Plan webite. 4. Mail or fax your completed and igned application to the addre/fax number below. 5. Once your application i proceed, you will receive notification of your acceptance in the New Brunwick Drug Plan with your premium and copayment detail and the effective date of your coverage.? How to reach u New Brunwick Drug Plan PO Box 690 Moncton, NB E1C 8M7 Toll-Free Number: Fax: Webite: gnb.ca/drugplan 1 Peronal information (required) Lat name: Firt name: Initial: Medicare number: Date of birth: DD / MM / YYYY Gender: male female Marital tatu: ingle married common-law eparated divorced Are you currently covered under a drug plan? ye no If ye, you mut complete an Exiting Drug Coverage form and end it with your completed application form. CONTACT INFORMATION Building number and treet: Apt.: City/town: Province: Potal code: Phone number: Alternate (e.g. mobile): SPOUSE (Your poue information i required even if your poue i not applying for coverage.) Lat name: Firt name: Initial: Medicare number: Date of birth: DD / MM / YYYY Gender: male female I your poue applying for coverage a well? ye no I your poue currently covered under a drug plan? ye no If ye to both quetion, you mut end a completed Exiting Drug Coverage form for your poue, along with your completed application form. Adminitered by Medavie Blue Cro on behalf of the Government of New Brunwick page 1 of 4 FORM-759KIT-E 01/18

14 2 New Brunwick Drug Plan Application for Coverage Form page 2 of 4 Dependant information (if applicable) Pleae lit all eligible dependant. If more pace i required, pleae attach a eparate heet. 3 Eligible dependant are defined a: all dependent children under the age of 19 all dependant age 19 or older who are eligible for a Diability Tax Credit under the federal Income Tax Act, AND were eligible for the tax credit a a minor, AND reide with the applicant Lat name: Firt name: Initial: Medicare number: Date of birth: DD / MM / YYYY Gender: male female Diabled (a per the definition above)? ye no I your dependant applying for coverage? ye no I your dependant currently covered under a drug plan? ye no If ye to both quetion, you mut end a completed Exiting Drug Coverage form for your dependant, along with your completed application form. Lat name: Firt name: Initial: Medicare number: Date of birth: DD / MM / YYYY Gender: male female Diabled (a per the definition above)? ye no I your dependant applying for coverage? ye no I your dependant currently covered under a drug plan? ye no If ye to both quetion, you mut end a completed Exiting Drug Coverage form for your dependant, along with your completed application form. Conent to releae income tax information (required) Your annual premium and maximum copayment will be calculated baed on your annual family income, a indicated on your Canada Revenue Agency (CRA) tax return for the mot recent tax year. Pleae chooe one of the following option: I conent to the releae of our family income, a indicated on our CRA tax return for the mot recent tax year. I/we hereby conent to the releae, by the Canada Revenue Agency to an official of the New Brunwick Department of Health and/or it Delivery Agent, of information from my/our income tax return, and, if applicable, other required taxpayer information about me/u, whether upplied by me/u or by a third party. The information will be relevant to, and ued olely for the purpoe of, determining and verifying my/our eligibility for benefit, required premium and entitlement for ubidy under the New Brunwick Drug Plan, and will not be dicloed to any other peron or organization without my/our approval. I/we undertand that, if I/we wih to withdraw thi authorization, I/we may do o at any time by writing to the New Brunwick Drug Plan. Thi authorization i valid for the current taxation year and each ubequent conecutive taxation year for which benefit under the New Brunwick Drug Plan may be requeted and determined. Applicant Social Inurance Number: I do not conent to the releae of our family income, a indicated on our CRA tax return for the mot recent tax year. We will be charged the maximum annual premium and the maximum copayment per precription. Name of Applicant: Signature of Applicant: Date of ignature: DD / MM / YYYY Name of Spoue: Spoue Social Inurance Number: Signature of Spoue: Date of ignature: DD / MM / YYYY Your poue conent i required even if your poue i not applying for coverage. Adminitered by Medavie Blue Cro on behalf of the Government of New Brunwick

15 New Brunwick Drug Plan Application for Coverage Form page 3 of 4 4 Payment information (required) Your monthly premium will be automatically deducted from your bank account each month. Pleae complete the Pre-authorized Debit (PAD) plan agreement below. PRE-AUTHORIZED DEBIT (PAD) PLAN AGREEMENT I authorize an official or repreentative or agent of the Department of Health (DH) or the New Brunwick Drug Plan, and the financial intitution deignated (or any other financial intitution I may authorize at any time) to begin deduction a per my intruction for recurring payment and/or one-time payment from time to time, for payment of inurance premium. Regular monthly payment for the full amount of ervice delivered will be debited to my pecified account on the firt buine day of every month. An official or repreentative or agent of the DH or the New Brunwick Drug Plan will not provide pre-notification but will provide a premium tatement indicating the amount of each regular debit. An official or repreentative or agent of the DH or the New Brunwick Drug Plan will obtain my authorization for any other one-time or poradic debit. An official or repreentative or agent of the DH or the New Brunwick Drug Plan require written notification of any change to banking information. Thi authority i to remain in effect until an official or repreentative or agent of the DH or the New Brunwick Drug Plan ha received written notification from me of it change or termination. Thi notification mut be received at leat ten (10) buine day before the next debit i cheduled. Thi notification mut be ent to the New Brunwick Drug Plan. I may obtain a ample cancellation form, or more information on my right to cancel a PAD Agreement at my financial intitution or by viiting I have certain recoure right if any debit doe not comply with thi agreement. For example, I have the right to receive reimburement for any PAD that i not authorized or i not conitent with thi PAD Agreement. To obtain a form for a Reimburement Claim, or for more information on my recoure right, I may contact my financial intitution or viit BANKING INFORMATION: pleae attach a void cheque or a direct depoit/pre-authorization payment form from your financial intitution and ign below. Signature of bank Date of account holder: ignature: DD / MM / YYYY If omeone other than the applicant or their poue will be paying the premium, pleae have them attach a void cheque or a direct depoit/pre-authorization payment form from their financial intitution and complete the information below: Lat name: Firt name: Initial: Building number and treet: Apt.: City/town: Province: Potal code: Phone number: Alternate (e.g. mobile): Signature of bank Date of account holder: ignature: DD / MM / YYYY Adminitered by Medavie Blue Cro on behalf of the Government of New Brunwick

16 New Brunwick Drug Plan Application for Coverage Form page 4 of 4 5 Peronal declaration, authorization and obligation (required) The ignature of your poue and all dependant over the age of 16 are required even if they are not applying for coverage. The name and ignature of a parent/guardian i required if: l The dependant i between the age of 16 and 18 (incluive) and doe not have the capacity to ign the peronal declaration and authorization; or l The dependant i 19 year of age or older and doe not have the capacity to ign the peronal declaration and authorization, or ha given legal authority for another peron to act on their behalf. Pleae attach a copy of the Power of Attorney for peronal care. By igning thi application form, I confirm that: I am applying to become a member of the New Brunwick Drug Plan, and I am providing information on thi form for thi purpoe. I undertand that I can withdraw my application and cancel my memberhip at any time. The information provided on thi form i true to the bet of my knowledge. I undertand that knowingly providing fale or incomplete information i an offence. I authorize the New Brunwick Drug Plan to collect my information from Medicare and other ource to verify the information on thi form and to verify eligibility for the New Brunwick Drug Plan. I agree to notify the New Brunwick Drug Plan immediately of any change that may affect my coverage. I undertand that the peronal information I provide, a well a any other peronal information currently held or collected in the future, may be collected, ued or dicloed to adminiter the New Brunwick Drug Plan. I authorize the New Brunwick Drug Plan to collect, ue and dicloe my peronal information a decribed above for a long a I remain a member of the New Brunwick Drug Plan. I undertand that I can revoke my conent at any time. In ome intance, revoking my conent may prevent the New Brunwick Drug Plan from providing me with the requeted coverage or benefit. I undertand that I mut pay my premium each month in order to receive benefit, and that if I do not pay my premium in full, benefit will not be provided and my coverage will be upended or cancelled. I undertand that failure to pay premium doe not mean that I have cancelled my New Brunwick Drug Plan coverage and that I mut contact the adminitrator in order to do o. I undertand that action will be taken to collect any outtanding premium owed. Name of Applicant: Signature of Applicant: Date of ignature: DD / MM / YYYY Name of Spoue: Signature of Spoue: Date of ignature: DD / MM / YYYY Name of Dependant (16 or older): Signature of Dependant: Date of ignature: DD / MM / YYYY Name of Dependant (16 or older): Signature of Dependant: Date of ignature: DD / MM / YYYY Thi information i collected under the authority of the Precription and Catatrophic Drug Inurance Act, SNB 2014, c 4, 12 and 13. Thi information will be ued and dicloed to adminiter the New Brunwick Drug Plan. It may be ued and dicloed in accordance with the Peronal Health Information Privacy and Acce Act, SNB 2009, c P For more information regarding collection and ue of peronal information, viit or contact the New Brunwick Drug Plan at the addre or telephone number hown on page 1 of thi application. Adminitered by Medavie Blue Cro on behalf of the Government of New Brunwick

17 Medavie Blue Cro Senior Precription Drug Program PLEASE COMPLETE THE FOLLOWING TO APPLY FOR BENEFITS Name: Addre: Telephone: Medicare No.: 644 MAIN ST PO BOX 220 MONCTON NB E1C 9N7 Date of Birth: Social Inurance No.: APPLICATION FORM Toll-Free Number: Fax: Potal Code: DD/MM/YY Language preference for correpondence: q Englih q French BENEFIT SELECTION - Pleae refer to the Medavie Blue Cro Senior Health Program booklet for a complete decription of the benefit. The amount hown below i a monthly rate. DRUG COVERAGE q $ Precription Drug Program Have you recently been covered by a Precription Drug Plan? q Ye If Ye, when will thi benefit terminate? AGREEMENT AND CONSENT q No DD/MM/YY I undertand that the peronal information provided herein, a well a any other peronal information currently held or collected in the future by Medavie Blue Cro and/or Blue Cro Life Inurance Company of Canada, may be collected, ued or dicloed to adminiter the term of my policy, to recommend uitable product and ervice to me and to manage Blue Cro buine. Depending on the type of coverage I carry, limited peronal information may be collected from and/or releaed to a third party. Thee third partie include other Blue Cro organization, health care profeional or intitution, life and health inurer, government and regulatory authoritie, and other third partie when required to adminiter and manage the benefit outlined in the policy of which I am an eligible member. I undertand that my peronal information will be kept confidential and ecure. I undertand that I may revoke my conent at any time; however, in ome intance doing o may prevent Blue Cro from providing me with the requeted coverage or benefit. I undertand why my peronal information i needed and I am aware of the rik and benefit of conenting or refuing to conent to it dicloure. A photocopy of thi authorization hall be a valid a the original. Thi information i collected under the authority of the Precription Drug Payment Act, SNB 1975, c P-15.01, 2. Thi information will be ued and dicloed to adminiter the New Brunwick Precription Drug Program. It may be ued and dicloed in accordance with the Peronal Health Information Privacy and Acce Act, SNB 2009, c P For more information regarding collection and ue of peronal information, viit or contact the New Brunwick Precription Drug Program at TM The Blue Cro ymbol and name are regitered trademark of the Canadian Aociation of Blue Cro Plan, ued under licence by Medavie Blue Cro, an independent licenee of the Canadian Aociation of Blue Cro Plan. Signature Date DD/MM/YY CONTINUED ON REVERSE FORM-070KIT-E 01/18

18 BILLING SELECTION q Monthly Pre-authorized Debit (PAD) (Pleae complete the Pre-authorized Debit (PAD) plan agreement below, ign, date and attach void cheque). I authorize Medavie Blue Cro, and the financial intitution deignated (or any other financial intitution I may authorize at any time), to begin deduction a per my intruction for recurring payment and/or one-time payment, from time to time, for payment of inurance premium. Regular monthly payment will be debited from my pecified account on the firt buine day of every month. Medavie Blue Cro will not provide monthly pre-notification but will provide 30-day notice if the deduction i ubject to change. Medavie Blue Cro will obtain my authorization for any other one-time or poradic debit. Medavie Blue Cro require written notification of any change to banking information. Thi authority i to remain in effect until Medavie Blue Cro ha received written notification from me of it change or termination. Thi notification mut be received at leat 30 buine day before the next debit i cheduled. Thi notification mut be ent to the Senior Health Program at Medavie Blue Cro. I may obtain a ample cancellation form or more information on my right to cancel a PAD Agreement at my financial intitution or by viiting I have certain recoure right if any debit doe not comply with thi agreement. For example, I have the right to receive reimburement for any PAD that i not authorized or i not conitent with thi PAD Agreement. To obtain a form for a Reimburement Claim, or for more information on my recoure right, I may contact my financial intitution or viit Authorized Signature: DATE: DD/MM/YY Type of Service: q Peronal q Buine Pleae attach a void cheque. (Credit card payment are not accepted.) (PLEASE PRINT) Financial Intitution (FI): Addre: City/Town: Province: Potal Code: FI Tranit Number: (tranit-5 digit; FI-3 digit) FI Account Number: If omeone other than the policy owner will be paying the premium, pleae have them ign, date and complete their financial information above and complete their peronal information below: Name: Addre: City/Town: Province: Potal Code: Phone Number: (Bu.) - - (Re.) - -

19 Medavie Blue Cro Senior Health Program PLEASE COMPLETE THE FOLLOWING TO APPLY FOR BENEFITS Name: Addre: Telephone: Medicare No.: 644 MAIN ST PO BOX 220 MONCTON NB E1C 9N7 APPLICATION FORM Toll-Free Number: Fax: Sale Potal Code: Date of Birth: DD/MM/YY Language preference for correpondence: q Englih q French BENEFIT SELECTION - Pleae refer to the Medavie Blue Cro Senior Health Program booklet for a complete decription of the benefit. The amount hown below are monthly rate. Pleae check all benefit you wih to include in your plan. HEALTH COVERAGE The following option do not include coverage for precription drug. q $10.00 Baic Health Benefit q $20.00 Enhanced Health Benefit (include the benefit under Baic) q $31.50 Hopital Reimburement Plan q $34.74 Individual Dental Benefit (billed eparately) Have you recently been covered for other health benefit, uch a Viion or Phyiotherapy? q Ye q No Have you been covered for dental benefit in the lat three month? q Ye q No If Ye, when will thee benefit terminate? DD/MM/YY Your coverage become effective on the firt day of the month of your 65 th birthday unle you are a late applicant or requet a different effective date. Requeted Effective Date of Policy: Pleae begin my coverage on the 1 t day of Month/Year AGREEMENT AND CONSENT I undertand that the peronal information provided herein, a well a any other peronal information currently held or collected in the future by Medavie Blue Cro and/or Blue Cro Life Inurance Company of Canada, may be collected, ued or dicloed to adminiter the term of my policy, to recommend uitable product and ervice to me and to manage Blue Cro buine. Depending on the type of coverage I carry, limited peronal information may be collected from and/or releaed to a third party. Thee third partie include other Blue Cro organization, health care profeional or intitution, life and health inurer, government and regulatory authoritie, and other third partie when required to adminiter and manage the benefit outlined in the policy of which I am an eligible member. I undertand that my peronal information will be kept confidential and ecure. I undertand that I may revoke my conent at any time; however, in ome intance doing o may prevent Blue Cro from providing me with the requeted coverage or benefit. I undertand why my peronal information i needed and I am aware of the rik and benefit of conenting or refuing to conent to it dicloure. A photocopy of thi authorization hall be a valid a the original. Thi conent complie with federal and provincial privacy law. For additional information regarding privacy policie at Medavie Blue Cro, viit medaviebc.ca or call Signature Date DD/MM/YY CONTINUED ON REVERSE TM The Blue Cro ymbol and name are regitered trademark of the Canadian Aociation of Blue Cro Plan, ued under licence by Medavie Blue Cro, an independent licenee of the Canadian Aociation of Blue Cro Plan. FORM-979KIT-E 01/18

20 q Quarterly Billing: four time a year (do not complete financial information below.) OR q Monthly Pre-authorized Debit (PAD) (Pleae complete the Pre-authorized Debit (PAD) plan agreement below, ign, date and attach void cheque). I authorize Medavie Blue Cro, and the financial intitution deignated (or any other financial intitution I may authorize at any time), to begin deduction a per my intruction for recurring payment and/or one-time payment, from time to time, for payment of inurance premium. Regular monthly payment will be debited from my pecified account on the firt buine day of every month. Medavie Blue Cro will not provide monthly pre-notification but will provide 30-day notice if the deduction i ubject to change. Medavie Blue Cro will obtain my authorization for any other one-time or poradic debit. Medavie Blue Cro require written notification of any change to banking information. Thi authority i to remain in effect until Medavie Blue Cro ha received written notification from me of it change or termination. Thi notification mut be received at leat 30 buine day before the next debit i cheduled. Thi notification mut be ent to the Senior Health Program at Medavie Blue Cro. I may obtain a ample cancellation form or more information on my right to cancel a PAD Agreement at my financial intitution or by viiting I have certain recoure right if any debit doe not comply with thi agreement. For example, I have the right to receive reimburement for any PAD that i not authorized or i not conitent with thi PAD Agreement. To obtain a form for a Reimburement Claim, or for more information on my recoure right, I may contact my financial intitution or viit Authorized Signature: DATE: DD/MM/YY Type of Service: q Peronal q Buine Pleae attach a void cheque. (Credit card payment are not accepted.) (PLEASE PRINT) Financial Intitution (FI): Addre: City/Town: Province: Potal Code: FI Tranit Number: (tranit-5 digit; FI-3 digit) FI Account Number: Would you like your claim reimburement automatically depoited in the ame account? q Ye q No If omeone other than the policy owner will be paying the premium, pleae have them ign, date and complete their financial information above and complete their peronal information below: Name: BILLING SELECTION Addre: City/Town: Province: Potal Code: Phone Number: (Bu.) - - (Re.) - - FOR OFFICE USE ONLY I hereby certify that, a an agent for Medavie Blue Cro, I have informed the applicant of the importance of making full and accurate dicloure of the matter covered in thi application and that any mirepreentation or omiion may give Medavie Blue Cro the right to cancel the contract of inurance and refue coverage under the policy. I have dicloed the company or companie I repreent and any conflict of interet they may have with repect to thi tranaction and that I may receive a alary, commiion or other form of compenation for the ale of inurance company product. Agent Name: Telephone Number: Addre: Agent Signature: Fax Number: Agent Number: