Read prism_spectra_rates.pdf text version

Prism Spectra Benefits

Please see "Benefit Descriptions" for more details

S1

$3,000 per year Paid at 90% Brand name drugs covered if no generic equivalent is available Not covered Not covered Not covered

S2

$3,000 per year Paid at 90% Brand name drugs covered if no generic equivalent is available $500 in the first 12 months $750 in the next 12 months $1,000 every 12 months thereafter Paid at 80% Paid at 60% in the first 12 months Paid at 70% in the next 12 months Paid at 80% thereafter Paid at 50%, starting in the 3rd benefit year

S3

$5,000 per year Paid at 90% Brand name drugs covered if no generic equivalent is available $1,000 in the first 12 months $1,000 in the next 12 months $1,250 every 12 months thereafter Paid at 80% Paid at 80% Paid at 50%, starting in the 3rd benefit year

PRESCRIPTION DRUGS - maximum

per person

DENTAL - Combined maximums per person for Schedules A, B & C (if applicable) Schedule A ­ Basic Schedule B ­ Basic Comprehensive

PRESCRIPTION DRU

Prescription drugs/medication prescription by law.

NOTE: Excludes vitamins, pa cessation products, er

Schedule C ­ Major Services

Not covered

DENTAL

Schedule A ­ Basic

EXTENDED HEALTH

Vision - maximum per person $150 every 24 months $150 in the first 24 months $200 in the next 24 months $300 every 24 months thereafter $5,000 per year Includes land and air $300 in the first 4 years $500 every 4 years thereafter $1,500 in the first 12 months $2,500 in the next 12 months $5,000 every 12 months thereafter $1,500 in the first 12 months $2,500 in the next 12 months $5,000 every 12 months thereafter foot orthotics - $250 every 24 months stockings - 2 pairs every 4 months surgical brassieres - 2 every 12 months Covered $65 every 24 months $150 in the first 24 months $200 in the next 24 months $300 every 24 months thereafter $10,000 per year Includes land and air $500 every 3 years $5,000 per year

Accidental Dental - maximum per person Ambulance Transportation Hearing Aids - maximum per person Home Support Services - maximum per person Medical Items - maximum per person

$5,000 per year Includes land and air $300 in the first 4 years $500 every 4 years thereafter $1,500 in the first 12 months $2,500 in the next 12 months $5,000 every 12 months thereafter $1,500 in the first 12 months $2,500 in the next 12 months $5,000 every 12 months thereafter foot orthotics - $250 every 24 months stockings - 2 pairs every 4 months surgical brassieres - 2 every 12 months Covered $50 every 24 months

· Preventative cleaning and p · Routine examinations, x-ra · Fluoride treatments for chil · Fillings and extractions · Pit and fissure sealants · Space maintainers and gen

Schedule B ­ Basic Compr

· Periodontal treatment inclu treatment of gums and tiss · Endodontics ­ root canal th · Denture cleaning, repairs, r

$5,000 per year foot orthotics - $250 every 24 months stockings - 2 pairs every 4 months surgical brassieres - 2 every 12 months

Schedule C ­ Major Servic

Medical Services Eye examinations - maximum per person Professional/Registered Therapists - maximums per practitioner per person · Chiropractor, Footcare Specialist (Chiropodist/Podiatrist), Naturopath, Osteopath, Physiotherapist, Massage Therapist, Acupuncturist · Psychologist, Speech Therapist

Covered $65 every 24 months

· Dentures · Standard crown restoration · Standard bridges, including · Standard repair or recemen

NOTE: All of the dental bene Association fee guide

$20 per visit; 20 visits per year $400 per year $1,000,000 per year 10 days per trip

$20 per visit; 20 visits per year $400 per year $1,000,000 per year 15 days per trip

$30 per visit; 20 visits per year $600 per year $1,000,000 per year 15 days per trip

Prism

TRAVEL - maximum per person [available up to age 65] SEMI-PRIVATE HOSPITAL ACCOMMODATION

Optional benefit - medical questionnaire required - maximum per person

This brochure outlines ben terms, conditions, limitatio Green Shield Canada upon

NOTE: Optional Benefit ­ Additional premium required, please refer to pages (6) and (7) $200 per day, 30 days per year $200 per day, 30 days per year $200 per day, 30 days per year

1

2

Benefit Descriptions Benefit Descriptions Benefit Descriptions Benefit Descriptions Benefit Descriptions

PRESCRIPTION DRUGS

prescription by law.

EXTENDED HEALTH

Medical Services Medical Services ServicesMedical Services Medical

Prescription eye glasses, contact lenses, laser eye surgery or replacement parts to prescription eye glasses.

Prescription drugs/medications that have been approved for use in Canada that require a PTION DRUGS DRUGS PRESCRIPTION PRESCRIPTION DRUGS EXTENDED HEALTH Vision EXTENDED HEALTH EXTENDED HEALTH

drugs/medications Prescription drugs/medications that have been in Canada a use in Canada that requireVision Prescription drugs/medications that have been approved for use approved for require a that have been approved for use in Canada that require that a Vision Vision NOTE: Excludes vitamins, patent or proprietary medicines, over-the-counter drugs, smoking by law. prescription by law. prescription by law. Prescription eye glasses, contact lenses, laser eye surgery or replacement parts tosurgery or replacement parts to Prescription eye glasses, contact lenses, laser eye surgery or replacement parts to Prescription eye glasses, contact lenses, laser eye cessation products, erectile dysfunction (ED) agents, fertility and obesity drugs. NOTE: For information regarding eye examinations please see description under prescription eye glasses. eye glasses. prescription prescription eye glasses. Medical Services. des vitamins, patent or proprietary vitamins, patent or proprietary medicines, drugs, smoking drugs, smoking NOTE: Excludes vitamins,Excludesor proprietary medicines, over-the-counter over-the-counter NOTE: patent medicines, over-the-counter drugs, smoking

Includes diagnostic tests and x-rays, dialysis equipment, laboratory tests, radioactive t and eye examinations.

NOTE: Eye examinationsexaminations Eye available only arethose provincesin thoseeye examinations eye not NOTE: Eye are available are examinations in available eye examinations are not NOTE: only in those provinces where only where provinces where are examinati tion products, erectile dysfunction (ED) agents, fertility and obesity drugs. cessation products, erectile dysfunction (ED) agents, fertility and obesity drugs.and obesity drugs. NOTE: For information regarding eye examinationsexaminations eye examinations please see description under cessation products, erectile dysfunction (ED) agents, fertility NOTE: For information regarding eye please see description under NOTE: For information regarding please see description under Professional/Registered Therapists Accidental Dental covered by the provincialthe provincial health plan on an government health plan on an annual basis. covered by government government health plan on an annual basis. covered by the provincial annual basis. Medical Services. Medical Services. Medical Services. Chiropractor, Footcare Specialists (Chiropodist/Podiatrist), Naturopath, Osteopath, The repair or replacement of natural teeth which were damaged as a result of an accident to the DENTAL Schedule A ­ Basic DENTAL Physiotherapist, Psychologist, Speech Therapist, Acupuncturist and Registered · Preventative cleaning and polishing (every 9 months) mouth (blow to the mouth). Professional/Registered Therapists Therapists Professional/Registered Professional/Registered Therapists Accidental Dental Accidental Dental Accidental Dental Massage Therapist (RMT). · Routine examinations, x-rays Chiropractor, Footcare Specialists (Chiropodist/Podiatrist), Naturopath, Naturopath, Chiropractor, Footcare Specialists (Chiropodist/Podiatrist), Naturopath, Osteopath, Schedule A ­ Basic ­ Basic Schedule A ­ Basic The repair or The repair or of natural teethor replacement of natural teeth which were damagedaccident to thean accident to the Chiropractor, Footcare Specialists (Chiropodist/Podiatrist), Osteopath, Osteopath, replacement replacement of natural were damaged as a result ofas aaccident to the a result of The repair which teeth which were damaged an result of an as · Fluoride treatments for children NOTE: Damage to teeth as a result of eating something is not covered. Physiotherapist, Psychologist, Psychologist, Speech Therapist, Acupuncturist andAcupuncturist and Registered Physiotherapist, Speech Therapist, Psychologist, Speech Therapist, Registered Physiotherapist, Acupuncturist and Registered · cleaning and cleaning and polishing (every 9 polishing (every 9 months) e Preventative polishing (every 9cleaning and months) · Preventative months) mouth (blow mouth mouth). the mouth). to the mouth). to the (blow to mouth (blow NOTE: All of the Extended Health benefits are not payable for services and supplies · Fillings and extractions Massage Therapist (RMT). Massage TherapistMassage Therapist (RMT). (RMT). aminations, x-rays · Routine examinations, x-rays · Routine examinations, x-rays a chronic care or psychiatric hospital or institution, chronic care unit of a gen · Pit and fissure sealants Ambulance Transportation eatments for childrenFluoride treatments for children · Fluoride treatments for children · NOTE: Damage to teeth as a to teeth as a result of eating something eating something is not covered. NOTE: Damage result of Damage to teeth as a result of is not covered. NOTE: eating something is not covered. or patient is confined to a nursing home or home for the aged and re · Space maintainers and general anaesthetics When required as the result of an accident or acute physical disability, professional land or air All of NOTE: All of the Extended when anot payableHealth benefits are not payable for services and supplies NOTE: the Extended Health benefits are benefits are for services and supplies and supplies provided in NOTE: All of the Extended not payable for services provided in Health d·extractions extractions and extractions Fillings and · Fillings provincial government assistance. ambulance to the nearest hospital equipped to provide the required treatment. a chronic care or psychiatricor psychiatriccare or psychiatric care unit or institution,hospital, care hospital, ge a chronic care hospital or institution,or institution, chronicacare unit of a general unit of a a chronic hospital chronic hospital of general chronic · Pit and fissure sealants fissure sealants ure sealants · Pit and Ambulance Ambulance Transportation Transportation Transportation Ambulance Schedule B ­ Basic Comprehensive or or when a patientor confined home is home for the aged andthe aged and for the nursing to a nursing home or nursing receives ntainers and general Spacegeneral anaesthetics · Space maintainers anaesthetics · and maintainers and general anaesthetics When required as the result as When required acute physical disability, professional physical air land or air When required of an accident or as the result acute physical disability, land or disability, professional land or air when a patient is confined toisawhen a patient or confined to ahome forhome or home receivesaged and the result of an accident or of an accident or acute professional TRAVEL · Periodontal treatment including: cleaning and scaling (8 units every 12 months) ­ Hearing Aids provincial government assistance. assistance. provincial government provincial government assistance. ambulance to the nearest hospital equipped to provide the required treatment.provide the required treatment. ambulance to the ambulance to the nearest hospital equipped to treatment. nearest hospital equipped to provide the required treatment of gums and tissues of the mouth Standard hearing aids, repairs or replacement parts. Schedule B ­ Basic Comprehensive Comprehensive ­ Basic Comprehensive B ­ Basic Schedule · Endodontics ­ root canal therapy TRAVEL TRAVEL Services that are required as a result of emergency illness or injuries which occurred TRAVEL l·treatment including: cleaning and cleaning(8 units every(8 units every­ months) every 12 months) ­ Hearing Aids Periodontal treatment including: scaling including: cleaning and scaling (8 units ­ · Periodontal treatment and scaling 12 months) 12 Hearing Aids Hearing Aids you were vacationing or traveling for other than health reasons. Covers hospital serv · Denture cleaning, repairs, rebasing and relining NOTE: Does not include the replacement cost for batteries. of treatment of gumsof thetissues gums and tissues of the mouth gums and tissues treatment of of the mouth and mouth Standard hearing aids, hearing or replacement parts. repairs or replacement parts. Standard repairs aids, repairs or replacement parts. Standard hearing aids, and accommodation, medical/surgical services, emergency transportation, repatriation Services that Services that as arequired as a result of emergency illness emergency which occurred while occurred are required are Services that are required as ainjuries of or injuries illness or injuries which result of emergency illness or result which occurred while · ­ root canal therapycanal therapyroot canal therapy s Endodontics ­ root · Endodontics ­ air ambulance. Schedule C ­ Major Services Home Support Services you were vacationing or traveling for other than health reasons. Covers hospitalhealth reasons. Covers hospital ser you were vacationing or traveling for othertraveling for other than services you were vacationing or than health reasons. Covers hospital services eaning, repairs, rebasing andrebasing and relining · Denture cleaning, Denture cleaning, repairs, rebasing and relining · repairs, relining NOTE: Does NOTE: Doesthe replacement cost for batteries. for batteries. cost for batteries. not include not include the replacement cost replacement NOTE: Does not include the · Dentures Services of a Registered Nurse (RN), Registered Practical Nurse (RPN), or Licensed Practical Nurse and accommodation, medical/surgical services, emergency transportation,andtransportation, repatriatio and accommodation, medical/surgical services, emergency transportation, repatriation repatriation and and accommodation, medical/surgical services, emergency NOTE: Travel Benefits are not available after the age of 65. · Standard crown restorations or onlays on natural teeth (LPN) in the home when certified medically necessary by the attending physician. air ambulance. ambulance. air ambulance. air ScheduleServicesSchedule C ­ Major Services ­ Major C ­ Major Services Home Support Services ServicesSupport Services Home Support Home · Standard bridges, including pontics, abutment retainers/crowns on natural teeth · Dentures · Dentures Services of a Services of a RegisteredRegistered Practical Nurse (RPN), Nurse (RPN),Practical Nurse Registered Nurse (RN), Nurse (RN), Registered Practical or Licensed or Licensed(RPN), or Licensed Practical Nurse Services of a Registered Nurse (RN), Registered Practical Nurse Practical Nurse SEMI-PRIVATE HOSPITAL ACCOMMODATION · Standard repair or recementing of crowns, onlays and bridgework on natural teeth Medical Items NOTE: TravelNOTE: Travel not available not available afternot available after the age of 65. Benefits are Benefits areTravel Benefits are65. age of 65. NOTE: after the age of the rown restorations · Standard crown restorations or onlays on natural teeth · Standard crown or onlays on or onlays on natural teeth restorations natural teeth (LPN) in the home when certified medically home when certified medicallyattending physician. (LPN) in the home(LPN) in the necessary by necessary by the necessary by the attending physician. when certified medically the attending physician. · Aids for daily living include: hospital style beds including rails and mattress, decubitus · Standard bridges, Standard bridges, including pontics, natural teeth natural teeth on natural teeth ridges, including pontics, abutment retainers/crowns on abutmenton · including pontics, abutment retainers/crowns retainers/crowns This (ulcer care) supplies, trapeze SEMI-PRIVATE HOSPITAL ACCOMMODATION cost between standard ward and semi-private SEMI-PRIVATEbenefit pays for theHOSPITAL ACCOMMODATION SEMI-PRIVATE difference in HOSPITAL ACCOMMODATION epair or recementingStandard repair or recementing of crowns, onlays and bridgework on natural teeth Medical Items · Standard repair · recementing of crowns, onlays andon natural teeth natural teeth or of crowns, onlays and bridgework bridgework on Medical Items Medical Items accommodation in a public or general (acute care) hospital when you have occupied NOTE: All of the dental benefits are based on the current Provincial Dental · Braces, casts, diabetic supplies (blood glucose monitor, lancets), catheter supplies, · Aids for dailyAids for daily living include: hospital style bedshospital style beds including rails and mattress, decubitus · living include: hospitalfor daily living include: including rails and mattress, decubitus · Aids style beds including rails and mattress, decubitus active treatment bed. Your provincial government health plan must accept or agree t Association fee guide for general practitioners. ostomy supplies, custom made foot orthotics This benefit pays for the difference in difference in cost between standardbetween standard ward and semi-private This benefit pays for the cost between the difference in cost ward and semi-private This benefit pays for standard ward and semi-private (ulcer care) supplies, trapeze (ulcer care) supplies, trapeze (ulcer care) supplies, trapeze pay the standard ward rate. · Mobility Aids include: cane, crutch, walker, wheelchair, traction equipment accommodation general (acute care) (acute or general (acuteoccupied an occupied an a public or general public when you have care) have NOTE: All of the dental based onare basedbenefits current Provincial current Provincial Dental NOTE: All of the dental on the are Dental the dental benefits are benefits the current Provincialbased on the Dental · Braces, casts,Braces, casts, diabetic supplies (blood glucose monitor, lancets), catheter supplies, catheter supplies, accommodation in a public orinaccommodation in ahospitalcare) hospital when youhospital when you have occupie · diabetic supplies Braces, glucose monitor, lancets), catheter supplies, · (blood casts, diabetic supplies (blood glucose monitor, lancets), · Prosthetics include: artificial limbs, eyes, prosthetic accessories, modifications and repairs, treatment bed. Your provincial government health plan must accept or agree to or agree toaccept or agree active active treatment bed. Your provincial government health plan must accept plan must active treatment bed. Your provincial government health iation fee guide for fee guide for general practitioners. Association general practitioners. guide for general practitioners. Association fee ostomy supplies, custom madecustom made footcustom made foot orthotics ostomy supplies, ostomy supplies, orthotics foot orthotics NOTE: · The semi-private benefit cannot be purchased on its own. surgical brassieres after a mastectomy pay the standard the standard wardthe standard ward rate. pay ward rate. pay rate. · Mobility Aids Mobility Aids include: cane, crutch, walker, wheelchair, traction equipment · include: cane, crutch, walker, wheelchair, traction equipment wheelchair, traction equipment · Mobility Aids include: cane, crutch, walker, · This benefit does not apply to accommodation in a long-term care facility Prism · Respiratory Cardiology includes: continuous positive airway pressure pump (CPAP), apnea · Prosthetics · Prosthetics include: artificialprosthetic artificial limbs, eyes, prosthetic repairs, and modifications and repairs, include: artificial limbs, eyes, limbs, eyes, prostheticmodificationsmodifications · Prosthetics include: accessories, accessories, and accessories, repairs, (i.e. chronic care facility/hospital), private This brochure outlines benefits available. This is not a contract. Actual details, monitor for respiratory disrhythmias (for infants), compressor, inhalant devices, tracheotomy · TheNOTE: · The benefit cannot be semi-private benefit cannot its own. hospital or program treatment fa NOTE: NOTE: · The purchased on its own. semi-private semi-private benefit cannot be purchased on be purchased on its own. surgical brassieres after a mastectomy mastectomy a mastectomy surgical brassieressurgical brassieres after after a · Benefits are not payable for hospitalization due to pregnancy or pregnancy terms, conditions, limitations and exclusions are detailed in the policy issued by supplies, oxygen · This not apply to accommodation a apply to care facility care facility · not apply to does This benefit accommodation in a long-term in a facility Prism Prism · Respiratory·Cardiology includes: continuous positive airway pressure pump positive apnea pressure pump (CPAP), apnea · This benefit does benefit doesconditions which innotlong-term accommodation (10) long-term carefollowin Respiratory Cardiology includes: continuous positive airway pressure pump (CPAP), apnea · Respiratory Cardiology includes: continuous (CPAP), airway commence during the first ten month period Green Shield Canada upon application approval. · Vascular compression includes: intermittent compression pump and sleeve, pressure gradient (i.e. chronic care facility/hospital), private hospital orprivate facility. (i.e. chronic care facility/hospital), program treatment facility. ureThis brochure outlines brochureavailable.benefits available. This Actual a contract. Actual details, outlines benefits This benefits outlines contract. Actual details,is not details, available. This is not a This is not a contract. monitor for respiratory disrhythmias disrhythmias compressor, inhalant devices, tracheotomy tracheotomy monitor for respiratory (forfor respiratory infants), compressor, inhalant devices, inhalant devices, tracheotomy (i.e. chronic care facility/hospital), private hospital or program treatment hospital or program treatment f monitor infants), (for disrhythmias (for infants), compressor, effective date of the coverage. surgical stockings · Benefits are not payable for hospitalization not payable for hospitalization due to pregnancy or pregnanc · Benefits are not· Benefits are due to pregnancyto pregnancy or pregnancy related payable for hospitalization due or pregnancy related ditions, limitations and exclusions are detailed in the policy issued policy issued by policy issued by terms, conditions, terms, conditions, limitations and exclusions are detailed in the limitations and exclusions are detailed in the by supplies, oxygen supplies, oxygen supplies, oxygen conditions which commence which commence during the first ten following period follow conditions during the month (10) following the eld Green Shield Canada upon application approval. Canada upon application approval. Green Shield Canada upon application approval. · Vascular compression compression includes:compression compression pumppressure gradient and sleeve, pressure gradient conditions which commence during the first ten (10) first tenperiodmonth period(10) monththe · Vascular includes: Vascular compression includes: intermittent compression pump gradient · intermittent intermittent pump and sleeve, and sleeve, pressure effective dateeffectivecoverage.the coverage. of the coverage. of the date of effective date surgical stockings stockings surgical stockings surgical

DENTAL

Includes diagnostic tests and x-rays, dialysis equipment, and x-rays, tests, radioactive treatments treatments Includes diagnostic tests and x-rays, dialysislaboratory dialysis equipment, laboratory tests, radioactive Includes diagnostic tests equipment, laboratory tests, radioactive NOTE: Eye examinations are available only in those provinces where eye examinatio and eye examinations. and eye examinations. eye examinations. and covered by the provincial government health plan on an annual basis.

3 3 3 3 4 4

4 4 5 5

5 5

Prism Spectra® - Monthly Rates Effective January 1, 2008

Rates and/or benefits are subject to change with thirty (30) days notice to the applicant/policy holder.

P

NOTE: Prism Spectra Monthly Rates do not include the Optional Semi-Private Hospital Accommodation benefit. Please refer to the Optional Semi-Private rate table for the additional premium required. Saskatchewan, Manitoba, Northwest Territories, Yukon Territory and Nunavut Family $121 $142 $172 $88 Single $37 $42 $53 $28 Couple $70 $80 $100 $52 Family $97 $113 $139 $67 Single $54 $62 $77 $68 New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland Single NA NA NA NA $52 $59 $73 $40 Couple $100 $113 $140 $76 Family $139 $160 $198 $95

British Columbia

Alberta

Ontario

Quebec

S1

Age 0-44 45-54 55-64 65+ Single $37 $42 $53 $28 Couple $70 $80 $100 $52 Family $97 $113 $139 $67 Single $46 $54 $64 $37 Couple $86 $103 $122 $70

Couple $103 $119 $148 $129

Family $142 $167 $207 $160

S2

Age 0-44 45-54 55-64 65+ Single $76 $82 $94 $67 Couple $143 $157 $180 $128 Family $208 $227 $260 $173 Single $82 $92 $104 $75 Couple $157 $175 $199 $142 Family $227 $255 $288 $196 Single $62 $68 $77 $52 Couple $117 $130 $146 $99 Family $168 $185 $210 $136 Single $94 $104 $122 $108 Couple $178 $201 $232 $207 Family $263 $294 $343 $270 NA NA NA NA Single $80 $90 $105 $69 Couple $152 $172 $199 $131 Family $218 $242 $284 $173

P

N

S3

Age 0-44 45-54 55-64 65+ Single $94 $99 $118 $83 Couple $179 $192 $227 $157 Family $247 $265 $299 $217 Single $106 $113 $134 $93 Couple $201 $215 $255 $174 Family $274 $295 $336 $238 Single $78 $83 $100 $66 Couple $150 $160 $194 $126 Family $199 $216 $248 $168 Single $120 $131 $157 $151 Couple $231 $249 $299 $288 Family $310 $337 $386 $361 NA NA NA NA Single $106 $114 $139 $89 Couple $200 $216 $264 $168 Family $266 $290 $333 $221

W

Optional Semi-Private Hospital Accommodation Monthly Rates

Rates and/or benefits are subject to change with thirty (30) days notice to the applicant/policy holder.

NOTE: The appropriate Semi-Private monthly rate below must be added to one of the plans above (S1, S2 or S3) if you wish to have the Optional Semi-Private Hospital Accommodation as a benefit. Age 0-44 45-54 55-64 65+ Single $4 $6 $8 $12 Couple $6 $8 $10 $18 Family $8 $10 $12 $21 Single $5 $7 $9 $16 Couple $7 $9 $11 $23 Family $9 $11 $14 $27 Single $4 $6 $8 $12 Couple $6 $8 $10 $18 Family $8 $10 $12 $21 Single $6 $8 $10 $18 Couple $8 $10 $12 $27 Family $10 $12 $15 $31 NA NA NA NA Single $5 $7 $9 $16 Couple $7 $9 $11 $23 Family $9 $11 $14 $27

Information

3 pages

Find more like this

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

1002614