EXTENDED HEALTH CARE Plan Document February 1, 1984 With Revisions Effective January 1, 1985 May 1, 1986 January 1, 1988 September 16, 1988 January 20, 1989 March 17, 1989 January 1, 1990 July 1, 1990 January 1, 1992 September 1, 1992 July 1, 1993 February 1, 1994 June 17, 1994 January 1, 1995 July 1, 1995 August 31, 1995 October 15, 1995 July 1, 1996 April 18, 1997 January 1, 1998 April 2, 1998 January 1, 1999 March 1, 1999 January 1, 2000 January 1, 2001 January 1, 2002 January 1, 2003 September 1, 2003 January 1, 2004 September 1, 2004 October 1, 2004 January 1, 2005 January 1, 2006 January 1, 2007 November 1, 2007 January 1, 2008 January 1, 2009 July 1, 2009 January 1, 2010 January 1, 2011 September 1, 2011 January 1, 2012 October 1, 2012 January 1, 2013 September 1, 2013 January 1, 2014 April 1, 2014 January 1, 2015 April 1, 2015 September 1, 2015 September 1, 2016 January 1, 2017 July 1, 2017
Table of Contents 1. Definition..1 2. Eligibility.6 3. Effective Date of Coverage 9 4. Restrictions on Availability of Coverage, Effective Date of Coverage, and Frequency of Choice.11 5. Termination of Coverage.12 6. Description of Extended Health Care Coverage Inside Canada 14 7. Outside Canada Emergency Travel Benefit 24 8. Generally Excluded Expenses 34 9. Coordination of Benefits Provision 36 10. Subrogation 40 11. General Provisions 44
1. DEFINITIONS (2017-01-01) 1.1. Actively At Work means an Employee is actively at work on any day in which an Employee performs the usual and customary duties of the Employee's occupation at the Employee's assigned location or at some other location where the Participating Employer requires the Employee to be (1996-07-01) 1.2. Added Choice Options 1 and 2 means benefits coverage combinations made available by the Trustees to Participating Employers, Employee Groups, and Covered Members (2017-01-01) 1.3. Alberta School Employee Benefit Plan is the trade name owned by the Trustees and under which This Plan and other employee benefit plans operate (1996-07-01) 1.4. Approved Provider means an entity that the Trustees in their sole discretion approve as a provider of services or supplies (2015-04-01) 1.5. Calendar Year means the period from any January 1 to the following December 31, inclusive 1.6. Compound means a therapeutic mixture containing one or more prescription medicine benefits as listed in the ASEBP Drug Benefit List which is prepared directly by and dispensed by a Recognized Health Care Professional (2014-04-01) 1.7. Covered Member means an Employee, Early Retiree, Part-Time Employee, School Trustee, or Substitute Teacher/Casual Employee who meets the conditions of eligibility, satisfies the effective date provisions, and who pays premiums or on whose behalf premiums are paid for coverage under This Plan. A Covered Member is associated with the Participating Employer that employs him/her, with which he/she was employed on the day of his/her retirement, on which board he/she sits as a School Trustee, or a Part-Time Employee or Substitute Teacher/Casual Employee designates upon application for coverage and with which he/she is included on a part-time employee or substitute teacher/casual employee roster (2013-01-01) 1.8. Dependant means a Dependant of the Covered Member who is (2009-01-01): 1.8.1. a spouse who is (2009-01-01): 1.8.1.1. legally married to the Covered Member, or (2009-01-01) 1.8.1.2. a person who is an adult interdependent partner pursuant to the Adult Interdependent Relationships Act Chapter A-4.5 of the Statutes of Alberta 2002 as amended (2003-09-01) 1.8.2. a child who is recognized as a Dependant child by a Canadian provincial government health plan (2009-01-01) Excluded as a Dependant is a Dependant who is not resident in Canada or who is on active duty in any military, naval or air force of any country, or peace-keeping force (2009-01-01) ASEBP Extended Health Care Plan Document 2017/07/01 1
1.9. Early Retiree means a person who is not working for a Participating Employer and who has agreed to participate in an early retirement agreement with the Trustees, but only if such person is (2004-01-01): 1.9.1. at least age 50 when retirement began, and (1986-05-01) 1.9.2. had at least 5 years consecutive employment with a Participating Employer(s) immediately prior to electing early retirement, and (1996-07-01) 1.9.3. is a resident of Canada 1.10. Early Retiree Package 1 means a predefined package of insurance and benefits available to Early Retirees under Added Choice Options 1 and 2 which may include Extended Health Care Plans 1, 2, or 5 under This Plan. The Plan 1, 2, or 5 determination is based upon which of these plans was in effect for the Employee Group from which the Early Retiree retired and in which the Early Retiree was participating immediately prior to his/her retirement (2004-09-01) 1.11. Early Retiree Package 2 means a predefined package of insurance and benefits available to Early Retirees who retire prior to September 1, 2011, under Added Choice Options 1 and 2 including Extended Health Care Plan 3 under This Plan (2011-09-01) 1.12. Employee means a person who is employed by a Participating Employer, but only if such person is a teacher, non-teacher involved directly in the operation and administration of the school system, or an employee of a related group whose participation is approved by the Trustees from time to time who is (2015-01-01): 1.12.1. under age 65, or if still Actively At Work, under age 70, and (1995-07-01) 1.12.2. employed for at least 0.2 full time equivalent, and (2004-01-01) 1.12.3. employed for at least the minimum hours set by the Participating Employer if they are greater than those set by the Trustees, and (2004-01-01) 1.12.4. a resident of Canada (2004-01-01) 1.13. Employee Group means the bargaining or other group to which an employee belongs (2004-09-01) 1.14. Family Coverage means coverage which includes both a Covered Member and one or more Dependants of the Covered Member (2004-09-01) 1.15. Hospital means a legally operated institution which: 1.15.1. engages in providing medical, diagnostic and surgical facilities for the care and treatment of sick and injured persons on an in-patient basis, and (1996-07-01) 1.15.2. is under the supervision of a staff of doctors with a 24-hour-a-day nursing service by registered nurses, and (1996-07-01) ASEBP Extended Health Care Plan Document 2017/07/01 2
1.15.3. is an institution accredited as a hospital by the Canadian Council on Hospital Accreditation approved for resident inpatient care under a provincial hospital services program, or if outside Canada a duly accredited hospital in that jurisdiction (1996-07-01) Excluded as a Hospital is any institution or part thereof which is (1) principally a home for the aged, rest home or nursing home, (2) for the care and treatment of drug addicts or alcoholics, (3) operating under the Mental Health Act, or (4) operating primarily as a school, or whose primary function is to furnish domiciliary or custodial care (1990-01-01) 1.16. Illness means a physical or mental disorder (1996-07-01) 1.17. Lowest Cost Alternative Price means the lowest priced medication per unit within any group of interchangeable alternatives in the Alberta Drug Benefit List (2016-09-01) 1.18. Maintenance Medication means a drug used to treat a chronic, long-term condition and is identified as a maintenance medication by the Trustees (2016-09-01) 1.19. Medically Necessary means those services and/or supplies that are required to diagnose or treat an Illness or injury, are consistent with the symptoms or diagnosis and treatment of the Illness or injury and are appropriate with regard to generally recognized and accepted standards of health care in Canada (2006-01-01) 1.20. Part-Time Employee means a person who is employed by a Participating Employer, but only if such person is a teacher, non-teacher involved directly in the operation and administration of the school system, or an employee of a related group whose participation is approved by the Trustees from time to time who is (2013-01-01): 1.20.1. under age 65, or if still Actively At Work, under age 70, and (2013-01-01) 1.20.2. employed for at least 0.2 full time equivalent, and (2013-01-01) 1.20.3. employed for less than the minimum hours set by the Participating Employer to participate in This Plan when those hours are greater than those set by the Trustees, and (2013-01-01) 1.20.4. a resident of Canada (2013-01-01) 1.21. Participating Employer means any school board or other employer approved by the Trustees whose application for Extended Health Care benefits for its Employees has been approved by the Trustees (2004-09-01) 1.22. Physician means a doctor of medicine duly licensed to practice medicine by the appropriate licensing authority where treatment is rendered and who is practising within the scope of his/her license (1996-07-01) 1.23. Preferred Price means the Lowest Cost Alternative Price or the Therapeutic Alternative Reference Price, whichever is less (2016-09-01) ASEBP Extended Health Care Plan Document 2017/07/01 3
1.24. Purchased Compound means a therapeutic mixture containing one or more prescription medicine benefits as listed in the ASEBP Drug Benefit List which is prepared directly by a compounding and repackaging pharmacy, purchased by a provider from the compounding and repackaging pharmacy and then dispensed by a Recognized Health Care Professional (2014-04-01) 1.25. Recognized Health Care Professional means an individual who is a member in good standing of a college or association that (2006-01-01): 1.25.1. is authorized by legislation applicable to the location where the service or supply is provided to register individuals who may order such services or supplies, where such recognition is required, or (2006-01-01) 1.25.2. in all other cases, is recognized by the Trustees (2006-01-01) 1.26. Service means the work an Employee is required to perform for the Employee's Participating Employer in accordance with the usual and customary duties relating to normal activities carried out to fulfil requirements of the position (1996-07-01) 1.27. School Trustee means a person who is appointed or elected as a School Trustee for a Participating Employer, but only if such person is (2004-01-01): 1.27.1. under age 65 at the time of appointment or election, or if serving a consecutive term in office, under age 70, and (2007-11-01) 1.27.2. a resident of Canada (2004-01-01) 1.28. Single Coverage means coverage for a Covered Member without coverage for Dependants (2004-09-01) 1.29. Substitute Teacher/Casual Employee means a person who is on a Participating Employer s roster of substitute teachers or casual employees, but only if such person is (2008-01-01): 1.29.1. under age 65, or if still Actively At Work, under age 70, and (2004-10-01) 1.29.2. a resident of Canada (2004-10-01) 1.30. Therapeutic Alternative Reference Price means the amount per unit that will be reimbursed for a medication within any group of therapeutic alternative medications established by the Trustees in their sole discretion and based upon the Manufacturer List Price in Alberta as published in the Alberta Drug Benefit List (2016-09-01) 1.31. This Plan means the Extended Health Care Plan described herein and operated by the Trustees (1996-07-01) 1.32. Trustees are those individuals who are appointed from time to time as trustees of the Alberta School Employee Benefit Plan pursuant to a Deed of Trust entered into by the Alberta School Boards Association and the Alberta Teachers Association. Whenever any right is conferred or obligation is imposed herein upon a Trustee or Trustees, it shall be conferred or imposed ASEBP Extended Health Care Plan Document 2017/07/01 4
upon the Trustees solely in their capacity as Trustees and not in their personal capacities (1996-07-01) 1.33. Voluntary Substitute Teacher/Casual Employee/Part-Time Employee Package means a predefined package of insurance and benefits available to Substitute Teachers/Casual Employees and Part-Time Employees under Added Choice Options 1 or 2 including Extended Health Care Plan 2 under This Plan (2017-01-01) ASEBP Extended Health Care Plan Document 2017/07/01 5
2. ELIGIBILITY 2.1. Eligibility by plan is as follows (2017-01-01): Plan Eligibility Plan 1 Employees of Participating Employers that select Added Choice Option 1 or 2 if Plan 1 is selected by the Participating Employer (2004-09-01) Early Retirees who were associated with a Participating Employer that selected Added Choice Option 1 or 2 and who elect Early Retiree Package 1 (2004-09-01) School Trustees of Participating Employers that select Added Choice Options 1 or 2 if the Participating Employer participates in Plan 1 with respect to nonteachers (2017-01-01) Plan 2 Employees of Participating Employers that select Added Choice Option 1 or 2 if Plan 2 is selected by the Participating Employer (2004-09-01) Early Retirees who were associated with a Participating Employer that selected Added Choice Option 1 or 2 and who elect Early Retiree Package 1 (2004-09-01) Part-Time Employees associated with a Participating Employer that selects Added Choice Options 1 or 2 (2017-01-01) School Trustees of Participating Employers that select Added Choice Options 1 or 2 if the Participating Employer participates in Plan 2 with respect to nonteachers (2017-01-01) Substitute Teachers/Casual Employees associated with a Participating Employer that selects Added Choice Options 1 or 2 (2017-01-01) Plan 3 Early Retirees who were associated with a Participating Employer that selected Added Choice Option 1 or 2 and who elect Early Retiree Package 2 prior to September 1, 2011 (2011-09-01) Plan 5 Employees of Participating Employers that select Added Choice Option 1 or 2 if Plan 5 is selected by the Participating Employer (2004-09-01) ASEBP Extended Health Care Plan Document 2017/07/01 6
Plan Eligibility Early Retirees who were associated with a Participating Employer that selected Added Choice Option 1 or 2 and who elect Early Retiree Package 1 (2004-09-01) School Trustees of Participating Employers that select Added Choice Options 1 or 2 if the Participating Employer participates in Plan 5 with respect to nonteachers (2017-01-01) 2.2. Date of eligibility is determined as follows (2006-01-01): 2.2.1. an Employee is eligible to be covered under This Plan on the later of: 2.2.1.1. the date the Employee s Participating Employer becomes included under This Plan, and 2.2.1.2. the date on which the Employee completes one day of Service, and (1995-08-31) 2.2.1.3. the date on which the Employee completes the waiting period set by the Participating Employer if greater than the period stipulated in paragraph 2.2.1.2 (2013-01-01) 2.2.2. an Early Retiree is eligible to be covered under This Plan the day after his or her retirement 2.2.3. a Part-Time Employee is eligible to be covered under This Plan on the later of (2013-01-01): 2.2.3.1. the date the Employee s Participating Employer becomes included under This Plan, and (2013-01-01) 2.2.3.2. the date on which the Employee completes one day of Service, and (2013-01-01) 2.2.3.3. the date on which the Employee completes the waiting period set by the Participating Employer if greater than the period stipulated in paragraph 2.2.3.2, and (2013-01-01) 2.2.3.4. the date on which the Participating Employer includes him or her on the part-time employee roster (2013-01-01) 2.2.4. a School Trustee is eligible to be covered under This Plan from the date of election or appointment to the participating school board (2004-09-01) ASEBP Extended Health Care Plan Document 2017/07/01 7
2.2.5. a Substitute Teacher/Casual Employee is eligible to be covered under This Plan when the Participating Employer includes him or her on the substitute teacher/casual employee roster (2008-01-01) 2.3. Eligibility for Early Retirees participating in Early Retiree Package 1 (2017-01-01): 2.3.1. shall be restricted to the plan (as described in paragraph 2.1), if any, provided from time to time to the Employee Group to which an Early Retiree belonged immediately prior to his or her retirement. Early Retirees shall cease to be eligible for any coverage under This Plan if and when the Early Retiree s former Employee Group ceases to be covered under This Plan (2015-01-01) 2.3.2. provided however that entitlement to coverage under the Early Retiree Packages is suspended as of the date the Early Retiree becomes eligible for group employment benefits through a Participating Employer or other school board and resumes subject to the terms of This Plan upon any resumption of Early Retiree status (2015-01-01) 2.4. Eligibility for Part-Time Employees shall be restricted to the plan (as described in paragraph 2.1) offered under the Added Choice Option of the Participating Employer designated in the Part-Time Employee s application for coverage. Eligibility ceases when the Part-Time Employee becomes eligible for group employment benefits through a Participating Employer or other school board (2013-01-01) 2.5. Eligibility for Substitute Teachers/Casual Employees shall be restricted to the plan (as described in paragraph 2.1) offered under the Added Choice Option of the Participating Employer designated in the Substitute Teacher/Casual Employee s application for coverage. Eligibility ceases when the Substitute Teacher/Casual Employee becomes eligible for group employment benefits through a Participating Employer or other school board (2008-01-01) 2.6. Eligibility is subject to policies, practices and decisions made or taken by the Trustees (2006-01-01): 2.6.1. requiring minimum levels of participation in This Plan or other plans offered by the Trustees as a condition for eligibility in This Plan (2006-01-01) 2.6.2. requiring the inclusion of other Employee Groups of the same Participating Employer in coverage under This Plan or other plans offered by the Trustees as a condition for eligibility in This Plan (2006-01-01) 2.6.3. terminating eligibility for coverage under This Plan or other plans offered by the Trustees in the event that a Participating Employer terminates coverage or the Trustees terminate coverage under This Plan or other plans offered by the Trustees (2006-01-01) 2.6.4. stipulating conditions upon which an Employee Group that was formerly covered under This Plan may be eligible for readmission to coverage under This Plan (2006-01-01) ASEBP Extended Health Care Plan Document 2017/07/01 8
3. EFFECTIVE DATE OF COVERAGE 3.1. An Employee s effective date of coverage is determined as follows (2017-01-01): 3.1.1. if participation is a condition of employment under Added Choice Option 1 or 2, an Employee must make application and the effective date of coverage is the date the Employee becomes eligible as long as the Employee is Actively at Work. If the Employee is not Actively at Work, the effective date of coverage is delayed until the Employee has been Actively at Work for one complete working day (2004-01-01) 3.1.2. if participation is optional under Added Choice Option 1 or 2, an Employee must make application and the effective date of coverage is the date the Trustees approve coverage as long as the Employee is Actively at Work. If the Employee is not Actively at Work, the effective date of coverage is delayed until the Employee has been Actively at Work for one complete working day (2004-09-01) 3.1.3. the effective date of subsequent changes to coverage is the date the Trustees approve such changes (2004-09-01) 3.2. An Early Retiree must make application and the effective date coverage is the date the Trustees approve coverage. The effective date of subsequent changes to coverage is the date the Trustees approve such changes (2004-09-01) 3.3. A Part-Time Employee must make application and the effective date of coverage is the date the Trustees approve coverage. The effective date of subsequent changes to coverage is the date the Trustees approve such changes (2013-01-01) 3.4. A School Trustee s effective date of coverage is determined as follows (2017-01-01): 3.4.1. under Added Choice Option 1 or 2, participation in coverage is mandatory for School Trustees when such coverage is a condition of employment for non-teachers. A School Trustee must make application and the School Trustee s effective date of coverage is the later of (2004-09-01): 3.4.1.1. November 1 of the year in which the term of office begins (2004-01-01) 3.4.1.2. the date of appointment or election if the School Trustee is appointed or elected at some time between the normal election dates (2004-01-01) 3.4.2. under Added Choice Option 1 or 2, participation in coverage is optional for School Trustees when such coverage is optional for non-teachers. A School Trustee must make application and the School Trustee s effective date of coverage is the date the Trustees approve coverage (2004-09-01) 3.4.3. the effective date of subsequent changes to coverage is the date the Trustees approve such changes (2004-09-01) 3.5. A Substitute Teacher/Casual Employee must make application and the effective date of coverage is the date the Trustees approve coverage. The effective date of subsequent changes to coverage is the date the Trustees approve such changes (2008-01-01) ASEBP Extended Health Care Plan Document 2017/07/01 9
3.6. A Covered Member must make application for coverage for Dependants and the effective date is the date the Trustees approve coverage. The effective date of subsequent changes to coverage is the date the Trustees approve such changes (2004-09-01) ASEBP Extended Health Care Plan Document 2017/07/01 10
4. RESTRICTIONS ON AVAILABILITY OF COVERAGE, EFFECTIVE DATE OF COVERAGE, AND FREQUENCY OF CHOICE (2017-01-01) 4.1. The Trustees may refuse to cover or may establish additional preconditions for coverage, including, but without restricting the generality of the foregoing, proof of good health, delayed effective dates of coverage, increased deductibles, or restrictions on coverage for any of the following individuals or Dependants of the following individuals who would otherwise be eligible for coverage, namely (2004-09-01): 4.1.1. anyone whose application for coverage is incomplete or who fails to provide the Trustees with necessary information to properly identify a Covered Member or Dependant (2004-09-01) 4.1.2. anyone who applies for coverage after a deadline established by the Trustees (2004-09-01) 4.1.3. anyone whose premiums are in arrears (2004-09-01) 4.1.4. anyone who elects coverage under This Plan for a leave of absence but purports to cancel such coverage after the commencement of the leave of absence (2004-09-01) 4.1.5. anyone who has previously opted out of coverage by the Trustees in favour of spousal or Dependant coverage under another plan and wishes to reinstate coverage with the Trustees (2004-09-01) 4.1.6. where the Covered Member is associated with a Participating Employer that selects Added Choice Options 1 or 2, anyone for whom coverage under This Plan was not mandatory and who has opted out of coverage or who has failed to apply for coverage (2004-09-01) 4.2. The effective date of coverage for any Covered Member or Dependant of a Covered Member who is associated with a Participating Employer for whom coverage under This Plan is not mandatory shall be determined by the Trustees at the time of application for coverage (2004-09-01) 4.3. Early Retirees must apply for coverage prior to retirement (2004-09-01) 4.4. Retroactive changes to coverage are not permitted (2003-09-01) ASEBP Extended Health Care Plan Document 2017/07/01 11
5. TERMINATION OF COVERAGE 5.1. A Covered Member s coverage terminates on the earlier of: 5.1.1. when the Covered Member ceases to be eligible, or 5.1.2. when This Plan terminates, or 5.1.3. the date of default in making payment of a required premium if the Trustees elect to terminate coverage, or (2004-09-01) 5.1.4. when the Covered Member ceases to be a resident of Canada, or 5.1.5. on June 30 coinciding with or next following the date on which the Employee reaches age 65, or if still Actively at Work, age 70, or (1995-07-01) 5.1.6. when the Employee is no longer in the Service of the Participating Employer, except that the Participating Employer may, without discrimination among Employees, continue to consider the Employee as being in Service, but no longer than 90 days following termination of Service for an Employee who is temporarily laid-off, or 5.1.7. 30 months from the commencement of a Participating Employer-approved leave of absence, or (2015-01-01) 5.1.8. a maximum extension of 18 months following the period referred to in paragraph 5.1.7 for an Employee who is on a Participating Employer-approved leave of absence and only when coverage during such extension is pre-approved by the Trustees (2015-01-01) 5.1.9. the last day of the month in which an Early Retiree reaches age 65, or (2004-01-01) 5.1.10. if any School Trustee is no longer eligible because he/she is age 65, coverage terminates on October 31 of the year in which a School Trustee s term of office ends or at age 70 should the School Trustee subsequently serve a consecutive term in office, or (2007-11-01) 5.1.11. the date a School Trustee is no longer serving in office (2004-01-01) 5.2. A Dependant s coverage terminates on the earlier of: 5.2.1. the Covered Member s coverage terminates, or 5.2.2. the Dependant ceases to be eligible under the definition of Dependant found in paragraph 1.8 However, if the Dependant s coverage terminates solely because of the death of an Employee, Early Retiree, or School Trustee, upon application coverage for benefits shall be continued on a premium-free basis until the earliest of the following dates (2004-10-01): 5.2.3. the date on which the surviving spouse remarries ASEBP Extended Health Care Plan Document 2017/07/01 12
5.2.4. the date which is one year from the date on which the Employee, Early Retiree, or School Trustee died (2004-10-01) 5.2.5. in respect only of the surviving spouse, the date on which the surviving spouse dies 5.2.6. in respect only of a surviving child, the date on which the Dependant dies, or ceases to qualify as a Dependant as defined in paragraph 1.8 The survivor s coverage will be restricted to the plan made available to the Employee Group to which the deceased Employee belonged (2007-01-01) ASEBP Extended Health Care Plan Document 2017/07/01 13
6. DESCRIPTION OF EXTENDED HEALTH CARE COVERAGE INSIDE CANADA ADDED CHOICE OPTIONS 1 AND 2 (2017-01-01) 6.1. Hospital Benefits: 6.1.1. Covered expenses: 6.1.1.1. This Plan covers expenses for semi-private hospital room charges during a confinement to a maximum of $148 per day (2017-07-01) 6.1.2. Limitations: 6.1.2.1. payment is subject to paragraph 8 Generally Excluded Expenses 6.1.2.2. expenses will be covered only if: 6.1.2.2.1. the confinement commences while the Employee or Dependant is covered under This Plan; an expense is considered to be incurred on the date the service or supply was provided, and 6.1.2.2.2. the confinement is Medically Necessary, and (2006-01-01) 6.1.2.2.3. unless expressly stipulated herein otherwise, the confinement, service or supply is ordered or prescribed by a Recognized Health Care Professional and provided by an Approved Provider (2015-04-01) 6.1.2.2.4. the confinement is one for which room charges are actually made by the Hospital, and (1996-07-01) 6.1.2.2.5. the Employee or Dependant is covered by a Canadian provincial government health plan, and (2000-01-01) 6.1.2.2.6. incurred for goods and services provided inside Canada (2009-01-01) 6.1.2.3. when expenses are for specialized treatment not available in the Covered Member s or Dependant s province of residence and the Covered Member or Dependant is referred outside his/her province of residence for the care of the Illness or accidental injury by a specialist, expenses are covered only when approved by the ASEBP, in writing, in ASEBP Extended Health Care Plan Document 2017/07/01 14
6.2. Prescription Medicine Benefits: 6.2.1. Covered expenses: advance of the procedures, services or supplies being provided (2009-01- 01) 6.2.1.1. This Plan covers the cost of medicines included in the ASEBP Drug Benefit List, which also outlines ASEBP defined over-the-counter products, subject to the following (1996-07-01): 6.2.1.1.1. smoking cessation products are covered to a combined lifetime maximum of $500 (1999-01-01) 6.2.1.1.2. contraception-related drug products are covered (2004-01- 01) 6.2.1.1.3. medicines prescribed for treating erectile dysfunction are covered to a maximum of $100 per month and $800 per person per calendar year (2017-01-01) 6.2.1.1.4. medicines prescribed for treating infertility are covered as follows (2002-01-01): 6.2.1.1.4.1. $800 per person per calendar year under Plan 1 (2002-01-01) 6.2.1.1.4.2. $600 per person per calendar year under Plan 2 (2002-01-01) 6.2.1.1.4.3. $600 per person per calendar year under Plan 3 (2002-01-01) 6.2.1.1.4.4. $720 per person per calendar year under Plan 5 (2002-01-01) 6.2.1.1.5. under Plan 1, 100% of the Preferred Price (2016-09-01) 6.2.1.1.6. under Plan 2, 80% of the Preferred Price (2016-09-01) 6.2.1.1.7. under Plan 3, 80% of the Preferred Price (2016-09-01) 6.2.1.1.8. under Plan 5, 90% of the Preferred Price (2016-09-01) 6.2.1.1.9. a maximum dispensing fee per prescription applies as follows (2014-04-01): 6.2.1.1.9.1. $9.00 for drugs including Purchased Compounds and excluding Compounds (2014-04-01) ASEBP Extended Health Care Plan Document 2017/07/01 15
6.2.1.1.9.2. $13.50 for Compounds (2014-04-01) 6.2.1.1.9.3. a maximum of five dispensing fees per Maintenance Medication per calendar year are covered (2016-09-01) 6.2.2. Limitations: 6.2.2.1. payment is subject to paragraph 8 Generally Excluded Expenses 6.2.2.2. the Trustees in their sole discretion may remove any medication from the ASEBP Drug Benefit List or apply conditions, restrictions or limitations on coverage for the cost of any medication included in the ASEBP Drug Benefit List respecting (2015-09-01): 6.2.2.2.1. the amount of costs to be covered by This Plan for any medication for a Covered Member or Dependant (2015-09- 01) 6.2.2.2.2. the quantity of any medication to be covered by This Plan for a Covered Member or Dependant (2015-09-01) 6.2.2.2.3. the provision of coverage for the cost of any medication through a special authorization process on an exception basis (2015-09-01) 6.2.2.2.4. the provision of coverage for the cost of any medication subject to any step therapy procedure (2015-09-01) 6.2.2.2.5. grandfathering or limiting coverage for the cost of any medication to Covered Members or Dependants using a medication prior to a date stipulated by the Trustees (2015-09-01) 6.2.2.2.6. exclusion of coverage for all or a portion of the cost of any medication also covered by a government or health authority program (2015-09-01) 6.2.2.2.7. any other condition, restriction or limitation (2015-09-01) Any such removal of a medication from the ASEBP Drug Benefit List, or condition, restriction or limitation may apply without notice to Covered Members or Dependants and shall take effect immediately or upon such later date as may be stipulated by the Trustees (2015-09-01) 6.2.2.3. expenses will be covered only if (2015-09-01): 6.2.2.3.1. incurred while the Employee or Dependant is covered under This Plan; an expense is considered to be incurred on the date the service or supply was provided, and ASEBP Extended Health Care Plan Document 2017/07/01 16
6.2.2.3.2. Medically Necessary, and (2006-01-01) 6.2.2.3.3. unless expressly stipulated herein otherwise, the confinement, service or supply is ordered or prescribed by a Recognized Health Care Professional and provided by an Approved Provider, and (2015-04-01) 6.2.2.3.4. the Employee or Dependant is covered by a Canadian provincial government health plan, and (2000-01-01) 6.2.2.3.5. in the case of medicines which require a prescription they are approved by the Health Canada Therapeutic Products Directorate (TPD) or its equivalent but only for the specific indications approved by the TPD, and (2015-09-01) 6.2.2.3.6. in the case of medicines not requiring a prescription and when listed in the ASEBP Drug Benefit List, if prescribed by a Physician and sold in a pharmacy, and (2004-01-01) 6.2.2.3.7. listed in the ASEBP Drug Benefit List, and (2015-09-01) 6.2.2.3.8. incurred for goods and services provided inside Canada (2009-01-01) 6.2.2.4. when expenses are for specialized treatment not available in the Covered Member s or Dependant s province of residence and the Covered Member or Dependant is referred outside his/her province of residence for the care of the Illness or accidental injury by a specialist, expenses are covered only when approved by the ASEBP, in writing, in advance of the procedures, services or supplies being provided (2009-01-01) 6.3. Major Medical Benefits: 6.3.1. Covered expenses: 6.3.1.1. This Plan covers expenses for the following (2009-07-01): 6.3.1.1.1. ambulance service, including air ambulance service in cases of emergency 6.3.1.1.2. dental services, subject to the following limitations (2006-01-01): 6.3.1.1.2.1. the services are for the treatment of accidental injury to teeth (including replacement of such teeth) or for the treatment of damage to healthy teeth as a result of biting on an object inserted in the mouth (1999-01-01) ASEBP Extended Health Care Plan Document 2017/07/01 17
6.3.1.1.2.2. the charges are incurred within two years of the accident (1998-01-01) 6.3.1.1.2.3. charges for services do not exceed $1,000 per tooth (1998-01-01) For this provision, accidental injury shall mean an injury suffered from an unforeseen and undesigned external blow to the mouth (1988-01-01). 6.3.1.1.3. psychological services provided by a psychologist, a provisional psychologist, or a person holding a master of social work degree in connection with the diagnosis and treatment of mental, nervous or emotional disorders, subject to the following limitations (2006-01-01): 6.3.1.1.3.1. charges for services do not exceed $1,200 per calendar year (2008-01-01) 6.3.1.1.3.2. charges for services do not exceed $100 for the first hour of each visit and $50 for each additional half hour of a visit (2007-01-01) 6.3.1.1.3.3. charges for services do not exceed one treatment per day (1998-01-01) 6.3.1.1.4. podiatry services, including x-rays related to podiatric treatment, subject to the following limitations (2012-01- 01): 6.3.1.1.4.1. charges for services do not exceed $700 per calendar year (1998-01-01) 6.3.1.1.4.2. charges for services, including x-rays related to podiatric treatment, do not exceed $50 per treatment (2014-01-01) 6.3.1.1.4.3. charges for services do not exceed one treatment per day (1998-01-01) 6.3.1.1.5. private duty nursing services in the home to a lifetime maximum of 4000 hours, subject to the following limitations (2006-01-01): 6.3.1.1.5.1. charges for services do not exceed $42 per hour for a registered nurse or registered psychiatric and mental deficiency nurse (2006-01-01) ASEBP Extended Health Care Plan Document 2017/07/01 18
6.3.1.1.5.2. charges for services do not exceed $27 per hour for a licensed practical nurse (2004-01- 01) 6.3.1.1.6. chiropractic, physiotherapy, acupuncture, and massage therapy services, including x-rays related to chiropractic treatment, to a combined maximum of $1,600 per calendar year, subject to the following limitations (2015-01- 01): 6.3.1.1.6.1. to a maximum of $700 per calendar year for chiropractic services (2006-01-01) 6.3.1.1.6.2. to a maximum of $700 per calendar year for physiotherapy services (2006-01-01) 6.3.1.1.6.3. to a maximum of $700 per calendar year for acupuncture services (2006-01-01) 6.3.1.1.6.4. to a maximum of $700 per calendar year for massage therapy services (2015-01-01) 6.3.1.1.6.5. charges for chiropractic services, including x-rays related to chiropractic treatment, do not exceed $50 per treatment (2015-01-01) 6.3.1.1.6.6. charges for physiotherapy services do not exceed $50 per treatment (2013-01-01) 6.3.1.1.6.7. charges for acupuncture services do not exceed $50 per treatment (2013-01-01) 6.3.1.1.6.8. charges for massage therapy services do not exceed $50 per treatment (2015-01-01) 6.3.1.1.6.9. charges for services do not exceed one treatment per day (1998-01-01) 6.3.1.1.7. oxygen, supplies required for its use including the purchase or rental of equipment, and shipping and repair charges to a combined maximum of $1,000 per calendar year (1998-01-01) 6.3.1.1.8. purchase or rental of canes, crutches, walkers, casts and cervical collars, subject to an individual maximum of $40 per category and a combined maximum of $100 per calendar year; repair charges are excluded (2014-01-01) 6.3.1.1.9. purchase or rental of wheelchairs or scooters as preapproved by the Trustees, including maintenance, repairs, ASEBP Extended Health Care Plan Document 2017/07/01 19
and replacement, to a combined maximum of $4,000 every four years (2014-01-01) 6.3.1.1.10. purchase or rental of hospital beds necessary because of a chronic medical condition as pre-approved by the Trustees to a lifetime maximum of $3,000 (2014-01-01) 6.3.1.1.11. purchase of allergy testing materials to a maximum of $40 per calendar year (2014-01-01) 6.3.1.1.12. purchase of digital blood pressure monitors to a maximum of $150 every three years; repair charges are excluded (1998-01-01) 6.3.1.1.13. purchase of insulin pumps to a maximum of $5,000 every four years and purchase of diabetic supplies excluding insulin pumps to a maximum of $4,000 per calendar year (2013-01-01) 6.3.1.1.14. purchase of hairpieces or wigs when loss of hair is due to a medical condition as pre-approved by the Trustees to a maximum of $600 every three years (2009-01-01) 6.3.1.1.15. purchase of mastectomy prostheses to a maximum of $400 per prosthesis per calendar year; repair charges and bras are excluded (2007-01-01) 6.3.1.1.16. purchase and repair of prosthetic eyes to a maximum of $500 every three years (2004-01-01) 6.3.1.1.17. purchase and repair of prosthetic larynxes to a maximum of $2,000 every three years (2004-01-01) 6.3.1.1.18. purchase and repair of prosthetic limbs and stockings to a combined maximum of $15,000 per limb and a maximum of one replacement every three years; myoelectric limbs included (2004-01-01) 6.3.1.1.19. purchase or rental of medical braces, including repairs, to a maximum of $500 per brace and a maximum of one replacement every two years (2014-01-01) 6.3.1.1.20. purchase of foot orthotics to a maximum of $200 per calendar year; repair charges are excluded (2006-01-01) 6.3.1.1.21. purchase of orthopedic shoes necessary because of an anatomical deformity to a maximum of $1,500 every two years; if a brace is a necessary part of the shoe, the brace must extend part way up the leg; repair charges are excluded (2014-01-01) ASEBP Extended Health Care Plan Document 2017/07/01 20
6.3.1.1.22. purchase of compression garments to a maximum of two pairs of support or surgical stockings/sleeves/gloves and to a combined maximum of $250 per calendar year (2015-01- 01) 6.3.1.1.23. purchase of dressings, bandages and related supplies necessary for the treatment of a chronic medical condition as pre-approved by the Trustees to a combined maximum of $600 per calendar year (2006-01-01) 6.3.1.1.24. purchase or rental of aerochambers to a maximum of $40 per aerochamber; repair charges are excluded (2014-01-01) 6.3.1.1.25. purchase or rental of respiratory and sleep apnea equipment and related apparatus, including repairs, to a combined maximum of $2,500 every five years (2014-01- 01) 6.3.1.1.26. purchase or rental of physical rehabilitation equipment to a lifetime maximum of $300; repair charges are excluded (2014-01-01) 6.3.1.1.27. the one-time purchase of phototherapy lights when required to treat seasonal affective disorder to a lifetime maximum of $300; repair charges are excluded (1998-01- 01) 6.3.1.1.28. the one-time purchase of ultra violet lights when required to treat psoriasis to a lifetime maximum of $300; repair charges are excluded (1998-01-01) 6.3.1.1.29. purchase of intravenous supplies to a maximum of $150 per calendar year (1998-01-01) 6.3.1.1.30. naturopathic services, subject to the following limitations (2006-01-01): 6.3.1.1.30.1. charges for services do not exceed $200 per calendar year (2000-01-01) 6.3.1.1.30.2. charges for services do not exceed $20 per treatment (2000-01-01) 6.3.1.1.30.3. charges for services do not exceed one treatment per day (2000-01-01) 6.3.1.1.31. purchase of ileostomy, colostomy, and urinary incontinence supplies to a combined maximum of $1,000 per calendar year and only when such supplies qualify for coverage under the Alberta Aids to Daily Living program (2004-01-01) ASEBP Extended Health Care Plan Document 2017/07/01 21
6.3.2. Limitations: 6.3.1.1.32. purchase of hearing aids and related supplies, maintenance, repairs, and replacement, subject to the following limitations (2006-01-01): 6.3.1.1.32.1. to a combined maximum of $3,000 every three years and a one-time lifetime maximum of $3,000 for expenses related to damage caused by an accident (2006-01-01) 6.3.1.1.32.2. charges for batteries, hearing tests and surgical implants are excluded (2006-01-01) 6.3.1.1.33. endovenous laser therapy or radiofrequency endovenous ablation for the treatment of varicose veins to a lifetime maximum of $4,000 (2014-01-01) 6.3.1.1.34. joint injectable materials for the treatment of osteoarthritis as pre-approved by the Trustees to a maximum of $1,000 per calendar year (2013-01-01) 6.3.2.1. payment is subject to paragraph 8 Generally Excluded Expenses 6.3.2.2. expenses will be covered only if (2015-01-01): 6.3.2.2.1. incurred while the Employee or Dependant is covered under This Plan; an expense is considered to be incurred on the date the service or supply was provided, and 6.3.2.2.2. Medically Necessary, and (2006-01-01) 6.3.2.2.3. unless expressly stipulated herein otherwise, the confinement, service or supply is ordered or prescribed by a Recognized Health Care Professional and provided by an Approved Provider ( 2015-04-01) 6.3.2.2.4. the Employee or Dependant is covered by a Canadian provincial government health plan, and (2000-01-01) 6.3.2.3. when expenses are for specialized treatment not available in the Covered Member s or Dependant s province of residence and the Covered Member or Dependant is referred outside his/her province of residence for the care of the Illness or accidental injury by a specialist, expenses are covered only when approved by the ASEBP, in writing, in advance of the procedures, services or supplies being provided (2009-01- 01) 6.3.2.4. when expenses are for medical supplies and equipment purchased from providers outside Canada any additional charges resulting from ASEBP Extended Health Care Plan Document 2017/07/01 22
purchasing the item from outside Canada are ineligible expenses (2015-01-01) ASEBP Extended Health Care Plan Document 2017/07/01 23
7. OUTSIDE CANADA EMERGENCY TRAVEL BENEFIT (1996-07-01) 7.1. Covered expenses: 7.1.1. This Outside Canada Emergency Travel Benefit is in addition to the provincial government medicare and hospital plans. This Plan covers expenses for the following required as a result of a medical emergency incurred outside Canada. For the purposes of this Outside Canada Emergency Travel Benefit a medical emergency is one in which medical treatment of an immediate nature is required as a result of an unforeseen accident or Illness; (2010-01-01): 7.1.1.1. accidental dental care usual, customary and reasonable charges, as determined by ASEBP, for services provided by a Recognized Health Care Professional for the repair, extraction and/or replacement of a Covered Member s or Dependant s natural or permanently attached artificial teeth damaged by a direct accidental external blow to the mouth to a maximum of two thousand dollars ($2,000.00) per Covered Member or Dependant per accident to natural or permanently attached artificial teeth. The injury must occur after the date the Covered Member or Dependant became eligible for Outside Canada Emergency Travel Benefit coverage and the Covered Member must see a Recognized Health Care Professional immediately following the accident. The repair, extraction and/or replacement must take place within one hundred eighty-two (182) days of the date of the accidental injury. An accident report will be required from the treating Recognized Health Care Professional (2013-01-01) 7.1.1.2. air ambulance services eligible expenses for air transportation to or from the nearest qualified medical facility able to provide medical care is also covered in the event that normal ground transportation is not available or in the best medical interest of the patient (2010-01-01) 7.1.1.3. ambulance services eligible expenses for services of a professional ambulance required to transport a patient, who is ill or has an injury, to or from the nearest qualified medical facility able to provide medical care. The ambulance must be licensed to operate in the jurisdiction where the service was rendered (2010-01-01) 7.1.1.4. cremation or burial - the cost of cremation or burial at the place of death, for the deceased Covered Member or Dependant up to two thousand five hundred dollars ($2500.00) (2010-01-01) 7.1.1.5. dental pain relief eligible expenses incurred for the treatment in a dental office for relief of dental pain excluding root canals to a maximum of three hundred dollars ($300.00) per Covered Member or Dependant per trip. Treatment must be rendered at a location at least two hundred (200) kilometres outside the Covered Member s or Dependant s provincial border (2013-01-01) ASEBP Extended Health Care Plan Document 2017/07/01 24
7.1.1.6. diagnostic services eligible expenses on the written order of a Recognized Health Care Professional and when pre-approval by the travel assistance service medical advisor has been given for laboratory tests and x-rays. Tests include but are not limited to MRI s, CAT scans and cardiac catheterization. For the purpose of this paragraph 7.1.1.6, diagnostic services refers to medically accepted tests required to identify the nature or extent of illness or injury and rendered to a Covered Member or Dependant in the office of a Recognized Health Care Professional, in a licensed general hospital or in a private facility approved by ASEBP, when such testing has been ordered by a Recognized Health Care Professional (2013-01-01) 7.1.1.7. drugs eligible expenses for prescription drugs, serums and administration of injectable drugs prescribed by a Recognized Health Care Professional and supplied by a licensed pharmacist which must have a Canadian equivalent, excluding vitamins (2010-01-01) 7.1.1.8. expenses to visit the Covered Member or Dependant (2010-01-01): 7.1.1.8.1. one round trip economy airfare, by the most direct route from Canada, will be reimbursed for a family member or a friend to visit a Covered Member or Dependant confined in hospital. This benefit requires the Covered Member or Dependant to have been an in-patient for at least three (3) days outside Canada, plus the written verification of the attending Physician that the situation is serious enough to have required the visit and pre-approval by the travel assistance service medical advisor has been given (2013-01- 01) 7.1.1.8.2. the extra costs for commercial accommodation or meals incurred by a family member or a friend visiting with a Covered Member or Dependant confined in hospital up to two hundred fifty dollars ($250.00) per day to a maximum of two thousand five hundred dollars ($2500.00) per incident. This must be verified by the attending Physician in writing that the situation is serious enough to have required the visit and supported with receipts from commercial organizations (2013-01-01) 7.1.1.9. expenses to identify the Covered Member or Dependant: 7.1.1.9.1. one round trip economy airfare, by the most direct route from Canada, will be reimbursed for a family member or a friend to identify the deceased prior to the release of the body, where necessary and pre-approval by the travel assistance service medical advisor has been given (2013-01- 01) ASEBP Extended Health Care Plan Document 2017/07/01 25
7.1.1.9.2. the extra costs for commercial accommodation or meals incurred by a family member or a friend associated with the trip to identify the deceased up to two hundred fifty dollars ($250.00) per day to a maximum of three (3) days per incident. This must be supported with receipts from commercial organizations (2013-01-01) 7.1.1.10. hospital accommodation eligible expenses for accommodation in a general active treatment hospital, less the amount allowed under the provincial government health program (2010-01-01) 7.1.1.11. incidental expenses miscellaneous expenses incurred by the Covered Member or Dependant inpatient as a result of hospitalization due to a medical emergency to a maximum of fifty dollars per day and five hundred dollars ($500.00) per Covered Member or Dependant per hospital stay. Payment allowance will be paid to the Covered Member or Dependant inpatient. Paid receipts must be submitted for reimbursement (2013-01-01) 7.1.1.12. meals and accommodations the extra costs of unavoidable additional expenses for commercial accommodation and meals incurred by a Covered Member or Dependant remaining with a travelling companion when return to the Covered Member s or Dependant s province of residence is delayed due to illness or injury to this travelling companion up to two hundred fifty dollars ($250.00) per day per Covered Member of Dependant to a maximum of two thousand five hundred dollars ($2500.00) per incident. This must be verified by the attending Physician and supported with receipts from commercial organizations (2013-01- 01) 7.1.1.13. medical aids eligible expenses on the written order of a Recognized Health Care Professional for canes, casts, crutches, slings, splints, trusses, walkers and/or temporary rental of a wheelchair (2010-01-01) 7.1.1.14. medical evacuation: 7.1.1.14.1. air ambulance services - the cost of air evacuation between hospitals or for hospital admission in the Covered Member s or Dependant s province of residence, at the discretion of the ASEBP or when ordered by the attending Physician or the travel assistance service medical advisor and approved by the ASEBP (2010-01-01) 7.1.1.14.2. repatriation - when the emergency is such that: 7.1.1.14.2.1. the attending Physician or the travel assistance service medical advisor specifies in writing that the Covered Member or Dependant should immediately return to ASEBP Extended Health Care Plan Document 2017/07/01 26