À¶Ý®ÊÓƵ

• Ambulance charges

• As authorized by the Assistive Devices Program (ADP)

Covered at 80%

$841Ìýper ear, per covered person, every 60 months

• The plan covers a number of medical supplies and equipment
• Must be prescribed in writing by a physician or nurse practitioner
• Predetermination of benefits must be submitted
• Some medical supplies may also be covered in part by government provincial plans under Assistive Device Programs (ADP)
• Examples of commonly covered items include wheelchairs, hospital beds, walkers, and oxygen

Covered at 80%

• On written recommendation of a physician,Ìýpodiatrist, or a chiropodist
• Custom-made foot orthotics or repairs to custom-made foot orthotics; Custom-made foot orthotics means devices made from a 3-dimensional model of an individual’s foot and made from raw materials. These devices are used to relieve foot pain related to biomechanical misalignment to the feet and lower limbs;
• Custom-made boots or shoes, modifications and repairs to orthopedic shoes or footwear as an integral part of a brace, (subject to a medical pre-authorization). Custom-made boots or shoes means footwear used by an individual whose condition cannot be accommodated by existing footwear products. The fabrication of the footwear involves making a unique cast of the covered person’s feet and the use of 100% raw materials. This footwear is used to accommodate the bony and structural abnormalities of the feet and lower legs resulting from trauma, disease or congenital deformities.

Covered at 80%

$841 every 2Ìýcalendar years

Reasonable and customary charges for three (3) pairs every two (2)Ìýcalendar years

• Plan pays the difference between provincial plan payment and reasonable and customary charges for medically necessary services and supplies as a result of a medical emergency
• Don’t leave home without your benefits ID card
• Refer to the out of country section for further details

100% up toÌý$5,000,000 per covered person per lifetime

Eligible paramedical practitioners:

• °ä³ó¾±°ù´Ç±è°ù²¹³¦³Ù´Ç°ù*Ìý
  
  
  Ìý
• Podiatrist**, Chiropodist, Osteopath, Registered Massage Therapist, Naturopath, Speech Therapist, Dietitian
  
  
  Ìý
• Physiotherapist*** (including visual training), Occupational Therapist***, Athletic Therapist***
  
  
  
  Ìý
• Psychologist****, Registered Social Worker****, Registered Psychotherapist – Eligible counselling services providers****
  Ìý

Covered at 80%

$841 per calendar year per type of practitioner

*$12 for the first 15 visits, Reasonable and Customary charges thereafter, up to $841 every calendar year

including 1 X-ray per calendar year, for Chiropractor, Podiatrist, and Osteopath

**OHIP annual maximum must be reached before claiming

***$841 per calendar year combined for all types of practitioners

****$1,067Ìýper calendar year combined for all types of practitioners
Ìý

• Enhanced generic drug substitution
• Trial prescription program available
• Prior authorization process applies for some medications and may be subject to participation in a health case management program
• Excludes weight loss and smoking cessation

To Request for Brand name Drug Coverage:

• If you have questions regarding this process,ÌýcontactingÌýGreenShield.

This form can be found on the Health Canada website, your doctor’s office, or your pharmacy may be able to provide it for you. Once completed by the medical doctor, the original form is sent to Health Canada Vigilance and the manufacturer, and a copy must be sent to GreenShield for assessment.

Covered at 80%

Dispensing fee cap is $7.00

Fertility drugs limited to $3000 lifetime maximum

• A Nursing Pre-Care Assessment, including a Medical Doctor Referral, must be submitted before home nursing begins
• Must be provided in the home by a registered nurse or registered or licensed practical nurse (not a relative)Ìý
• Does not apply to rehabilitation or long-term care facilities, or services deemed custodial by insurance carrier
• Out of pocket maximum does not apply to this benefit

Covered at 80% for the first 10 days in each calendar year; 100% thereafter up to a maximum of $25,478

• Eye examinations, including refractions, when they are performed by a licensed ophthalmologist or optometrist

100% coverage up to $85 per person every 24 months.

This benefit is available only whenÌýeye examinations are not covered by the provincial health insurance plan

• Continuous glucose monitors (CGM)* and flash glucose monitors (FGM)**, coverage includes the monitors themselves as well as sensors and transmitters
• Note: CGM claims do not have to be manually submitted for reimbursement. All GMS items can be submitted directly at the point of sale from the pharmacy. The required pins needed for the pharmacy online submissions are posted on the ProviderConnect website. As well, GreenShield Customer Service agents are trained to provide these to pharmacies who call for billing support. For members with claims, GreenShield will apply continuation of coverage, and prior authorization requirements will not apply

  
  If you or your pharmacist have questions regarding this, contactÌýGreenShield.

80% coinsurance to a maximum of $4,000 per calendar year per person (maximum applies to CGM and FGM on a combined basis)Ìý

Ìý
* A pre-treatment form (estimate) is required for machines and supplies
patient must be insulin dependent to be eligible

** Prescribed by a physician
Patient must be insulin dependent to be eligible

• Eligible expenses: anesthetist fees; cycle monitoring fee; 1 ultrasound and blood test once the in vitro procedure has begun; embryo freezing – initial process, preparation, and annual storage limit of 1 year; embryo thawing; in vitro fertilization procedure; sperm thawing; sperm washing; transfer of frozen embryo, medical expenses or services incurred by the surrogate mother.
• Ineligible expenses: embryo donation program; donation to a sperm bank; egg freezing; donor’s fee or cost, adoption, surrogacy agency fee, and surrogate mother's fee.

• Claims Process for Surrogacy: Expenses need to be incurred by a surrogate within a fertility clinic in Canada. To obtain reimbursement for these expenses, a copy of the legal surrogacy agreement must be submitted to the extended health insurance providerÌýwith the first claim. Surrogacy claims are reimbursed to the plan member and subject to plan limitations and maximums.

A $30,000 lifetime maximum per member.

Patient must be age 43 and under.
Ìý

Ìý

• Applicable to public hospitals in the province of residence
• Does not apply to rehabilitation or long-term care facilities, or services deemed custodial by insurance carrier
• Out of pocket maximum does not apply to this benefit

Covered at 80% for the first 5 days in each calendar year; 100%ÌýthereafterÌý

Homewood is limited to a lifetime maximum of 60 days

• Coverage includes basic preventative dental expenses such as regular oral examinations, x-rays, fillings, extractions, root canals and periodontal scalingÌý
• Payment for recall examinations (includes examinations, x-rays, cleaning) is limited to once every 9 months with 16 units of scaling per calendar year

95% of the current feeÌýguide in effect to a maximum of $2,803Ìýper year per covered person

• Includes bridges, crowns and onlays, including some denture expenses

50% of the fee guide in effect to a maximum of $4,224Ìýper year per covered person

• Includes braces and teeth straightening including correction, observation, and adjustment
• Includes adult orthodontics

50% of the fee guide in effect to a lifetime maximum of $4,224Ìýper covered person

• Faculty, non-union staff university support group (USG) 5 and above (full and part-time)

180 calendar days salary continuance

• All other employees (including Canadian Union of Public Employees (CUPE) Local 793)

90 calendar days salary continuance

• After 5 years of service, one additional day credited for each complete month worked; maximum credited sick leave is 180 calendar days
• CUPE Local 793 employees limited to a maximum of three days during the initial probationary period (see Article 19)

• All employee groups

• 85% of prescribed pre-LTD net salary to a maximum insured salary of $190,549 tax-free
• Unable to perform regular duties of own occupation during the qualifying period and the subsequent two years
• Unable to work atÌýanyÌýoccupation after 2 yearsÌý
  • Any occupation is defined as any job for which you are qualified or may reasonably become qualified by training, education, or experience

• One (1) times your annual base salary

Maximum coverage is the lesser of 6 times employee annual base salary or $2,000,000

• One (1) to two (2) times your annual basic salary
• Medical evidence is required for coverage in excess of $600,000 (combined with basic life) or for any amount after 31 days from date of hire

• one (1) to three (3) times annual base salary
• Medical evidence is required

• 1 times to 6 times annual salary
• Medical evidence is required

$200,000

• For accidental death that occurs while travelling on University business (refer toÌýPolicy 31Ìýfor more information)