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THE KETTLE FRIENDSHIP SOCIETY Casual Employees
Great-West Life is a leading Canadian life and health insurer. Great- West Life's financial security advisors work with our clients from coast to coast to help them secure their financial future. We provide a wide range of retirement savings and income plans; as well as life, disability and critical illness insurance for individuals and families. As a leading provider of employee benefits in Canada, we offer effective benefit solutions for large and small employee groups. Great-West Life Online Information and details on Great-West Life's corporate profile, our products and services, investor information, news releases and contact information can all be found at our website www.greatwestlife.com.
Great-West Life Online Services for Plan Members As a Great-West Life plan member, you can also register for GroupNet™ for Plan Members at www.greatwestlife.com. This service enables you to access the following and much more, within a user friendly environment twenty-four hours a day, seven days a week: your benefit details and claims history
online claim submission for certain healthcare claims and all dental
extensive health and wellness content Great-West Life’s Toll-Free Number To contact a customer service representative at Great-West Life for assistance with your medical and dental coverage, please call 1-800-957-9777.
This booklet describes the principal features of the group benefit plan sponsored by your employer, but Group Policy No. 162661 issued by Great-West Life is the governing document. If there are variations between the information in the booklet and the provisions of the policy, the policy will prevail. This booklet contains important information and should be kept in a safe place known to you and your family. The Plan is underwritten by Protecting Your Personal Information
At Great-West Life, we recognize and respect the importance of privacy. Personal information about you is kept in a confidential file at the offices of Great-West Life or the offices of an organization authorized by Great- West Life. Great-West Life may use service providers located within or outside Canada. We limit access to personal information in your file to Great-West Life staff or persons authorized by Great-West Life who require it to perform their duties, to persons to whom you have granted access, and to persons authorized by law. Your personal information may be subject to disclosure to those authorized under applicable law within or outside Canada. We use the personal information to administer the group benefits plan under which you are covered. This includes many tasks, such as:
determining your eligibility for coverage under the plan
investigating and assessing your claims and providing you with
verifying and auditing eligibility and claims creating and maintaining records concerning our relationship
underwriting activities, such as determining the cost of the plan, and
analyzing the design options of the plan
preparing regulatory reports, such as tax slips
We may exchange personal information with your health care providers, your plan administrator, any insurance or reinsurance companies, administrators of government benefits or other benefit programs, other organizations, or service providers working with us or the above when relevant and necessary to administer the plan.
As plan member, you are responsible for the claims submitted. We may exchange personal information with you or a person acting on your behalf when relevant and necessary to confirm coverage and to manage the claims submitted. You may request access or correction of the personal information in your file. A request for access or correction should be made in writing and may be sent to any of Great-West Life’s offices or to our head office. For a copy of our Privacy Guidelines, or if you have questions about our personal information policies and practices (including with respect to service providers), write to Great-West Life’s Chief Compliance Officer or refer to www.greatwestlife.com.
TABLE OF CONTENTS
Commencement and Termination of Coverage
Healthcare 6 Preferred Vision Services (PVS)
Diagnostic and Treatment Support Services (Best Doctors® Service) 30
Benefit Summary This summary must be read together with the benefits described in this booklet.
Healthcare Covered expenses will not exceed customary charges
The individual and family deductibles do not apply to Chronic Care, Global Medical Assistance, Visioncare, In-Canada Prescription Drugs, In-Canada Hospital and Accidental Dental Injury expenses
In-Canada Prescription Drug, Visioncare, Chronic Care, Accidental Dental Injury, and In-Canada Hospital Expenses
Out-of-Country Care Expenses - Emergency Care
80% of the first $1,000 of paid expenses each calendar year and 100% of the remainder
Custom-fitted Orthopedic Shoes and Custom-made Foot Orthotics
Blood-glucose Monitoring Machines 1 every 4 years Transcutaneous Nerve Stimulators
$200 each calendar year, excluding x-rays
1 every 24 months to a maximum of $50 every 24 months
Glasses, Contact Lenses and Laser Eye Surgery
Out-of-Country Care Maximums - Emergency Care Expenses
Dentalcare Covered expenses will not exceed customary charges
The dental fee guide in effect on the date treatment is rendered for the province in which treatment is rendered
COMMENCEMENT AND TERMINATION OF COVERAGE
You are eligible to participate in the plan on the first day of the month following your completion of the probationary period.
You and your dependents will be covered as soon as you become
You may waive health and/or dental coverage if you are already covered for these benefits under your spouse's plan. If you lose spousal coverage you must apply for coverage under this plan. If you do not apply within 31 days of loss of such coverage, or you were previously declined for coverage by Great-West Life, you and your dependents may be required to provide evidence of insurability acceptable to Great-West Life to be covered for health benefits, and may be declined for or offered limited dental benefits.
You must be actively at work when coverage takes effect, otherwise
the coverage will not be effective until you return to work.
Increases in your benefits while you are covered by this plan will not become effective unless you are actively at work.
Temporary and seasonal employees, and part-time employees who
work less than 15 hours per week may not join the plan.
Your coverage terminates when your employment ends, you are no longer eligible, or the policy terminates, whichever is earliest.
Your dependents' coverage terminates when your insurance
terminates or your dependent no longer qualifies, whichever is earlier.
When your coverage terminates, you may be entitled to an
extension of benefits under the plan. Your employer will provide you with details.
If you die while your coverage is still in force, the health and dental benefits for your dependents will be continued for a period of 2 years or until they no longer qualify, whichever happens first. DEPENDENT COVERAGE
Your unmarried children under age 21, or under age 25 if they are
Children under age 21 are not covered if they are working more than 30 hours a week, unless they are full-time students.
Children who are incapable of supporting themselves because of physical or mental disorder are covered without age limit if the disorder begins before they turn 21, or while they are students under 25, and the disorder has been continuous since that time.
A deductible may be applied before you are reimbursed. All expenses will be reimbursed at the level shown in the Benefit Summary. Benefits may be subject to plan maximums and frequency limits. Check the Benefit Summary for this information. The plan covers customary charges for the following services and supplies. All covered services and supplies must represent reasonable treatment. Treatment is considered reasonable if it is accepted by the Canadian medical profession, it is proven to be effective, and it is of a form, intensity, frequency and duration essential to diagnosis or management of the disease or injury. Covered Expenses Ambulance transportation to the nearest centre where adequate
Semi-private room and board in a hospital in Canada
For out-of-province accommodation, any difference between the hospital's standard ward rate and the government authorized allowance in your home province is covered.
The plan also covers the hospital facility fee related to dental surgery and any out-of-province hospital out-patient charges not covered by the government health plan in your home province.
Convalescent care for a condition that will significantly improve as a
result of the care and follows a 3-day confinement for acute care
The government authorized co-payment for accommodation in a
nursing home. Residences established primarily for senior citizens or which provide personal rather than medical care are not covered.
Home nursing services of a registered nurse, licensed practical
nurse or registered nursing assistant who is not a member of your family, when services are provided in Canada, but only if the patient requires the specific skills of a trained nurse
You should apply for a pre-care assessment before home nursing begins
Chronic care, provided in a hospital, nursing home or for home
nursing care in Canada, for a condition where improvement or deterioration is unlikely within the next 12 months
Drugs and drug supplies described below when prescribed by a
physician or other person entitled by law to prescribe them, and provided in Canada. Benefits for drug expenses outside Canada are payable only as provided under the out-of-country care provision.
Drugs which require a written prescription according to the Food and Drugs Act, Canada or provincial legislation in effect where the drug is dispensed, including oral contraceptives
Injectable drugs including vitamins, insulins and allergy extracts. Syringes for self-administered injections are also covered
Disposable needles for use with non-disposable insulin injection devices, lancets and test strips
Extemporaneous preparations or compounds if one of the ingredients is a covered drug
Certain other drugs that do not require a prescription by law may be covered. If you have any questions, contact your plan administrator before incurring the expense.
Unless the prescriber has prescribed a drug by its brand name and has specified in writing that the product is not to be interchanged, the plan will cover only the cost of the lowest priced equivalent generic drug.
For drugs eligible under a provincial drug plan, coverage is limited to the deductible amount and coinsurance you are required to pay under that plan.
Rental or, at Great-West Life's discretion, purchase of certain
medical supplies, appliances and prosthetic devices prescribed by a physician
Custom-made foot orthotics and custom-fitted orthopedic shoes,
including modifications to orthopedic footwear, when prescribed by a physician
Hearing aids, including batteries, tubing and ear molds provided at
the time of purchase, when prescribed by a physician
Diabetic supplies, including insulin, syringes, Novolin pens, testing
supplies and insulin infusion sets, when prescribed by a physician
Blood-glucose monitoring machines prescribed by a physician
Diagnostic x-rays and lab tests, when coverage is not available
Treatment of injury to sound natural teeth. Treatment must start
within 60 days after the accident unless delayed by a medical condition
A sound tooth is any tooth that did not require restorative treatment immediately before the accident. A natural tooth is any tooth that has not been artificially replaced
dental treatment completed more than 12 months after the accident
orthodontic diagnostic services or treatment
Out-of-hospital services of a qualified acupuncturist
Out-of-hospital treatment of muscle and bone disorders, including
diagnostic x-rays, by a licensed chiropractor
Out-of-hospital services of a qualified massage therapist
Out-of-hospital services of a licensed naturopath
Out-of-hospital treatment of movement disorders by a licensed
Out-of-hospital treatment of foot disorders, including diagnostic
Out-of-hospital treatment of speech impairments by a qualified
Eye examinations, including refractions, when they are performed by
a licensed ophthalmologist or optometrist, and coverage is not available under your provincial government plan
Glasses and contact lenses required to correct vision when provided
by a licensed ophthalmologist, optometrist or optician
Laser eye surgery required to correct vision when performed by a
For information on available discounts on eyewear and vision care services, refer to the Preferred Vision Services section of this booklet following the Healthcare benefit.
Global Medical Assistance Program This program provides medical assistance through a worldwide communications network which operates 24 hours a day. The network locates medical services and obtains Great-West Life's approval of covered services, when required as a result of a medical emergency arising while you or your dependent is travelling for vacation, business or education. Coverage for travel within Canada is limited to emergencies arising more than 500 kilometres from home. You must be covered by the government health plan in your home province to be eligible for global medical assistance benefits. The following services are covered, subject to Great-West Life's prior approval:
On-site hospital payment when required for admission, to a
If suitable local care is not available, medical evacuation to the
nearest suitable hospital while travelling in Canada. If travel is outside Canada, transportation will be provided to a hospital in Canada or to the nearest hospital outside Canada equipped to provide treatment
When services are covered under this provision, they are not covered under other provisions described in this booklet
Transportation and lodging for one family member joining a patient
hospitalized for more than 7 days while travelling alone. Benefits will be paid for moderate quality lodgings up to $1,500 and for a round trip economy class ticket
If you or a dependent is hospitalized while travelling with a
companion, extra costs for moderate quality lodgings for the companion when the return trip is delayed due to your or your dependent’s medical condition, to a maximum of $1,500
The cost of comparable return transportation home for you or a
dependent and one travelling companion if prearranged, prepaid return transportation is missed because you or your dependent is hospitalized. Coverage is provided only when the return fare is not refundable. A rental vehicle is not considered prearranged, prepaid return transportation
In case of death, preparation and transportation of the deceased
Return transportation home for minor children travelling with you or
a dependent who are left unaccompanied because of your or your dependent’s hospitalization or death. Return or round trip transportation for an escort for the children is also covered when considered necessary
Costs of returning your or your dependent's vehicle home or to the
nearest rental agency when illness or injury prevents you or your dependent from driving, to a maximum of $1,000. Benefits will not be paid for vehicle return if transportation reimbursement benefits are paid for the cost of comparable return transportation home
Benefits payable for moderate quality accommodation include telephone expenses as well as taxicab and car rental charges. Meal expenses are not covered.
Emergency care outside Canada is covered if it is required as a
result of a medical emergency arising while you or your dependent is temporarily outside Canada for vacation, business or education purposes. To qualify for benefits, you must be covered by the government health plan in your home province.
A medical emergency is either a sudden, unexpected injury, or a sudden, unexpected illness or acute episode of disease that could not have been reasonably anticipated based on the patient’s prior medical condition.
Emergency care is covered medical treatment that is provided as a result of and immediately following a medical emergency.
If the patient’s condition permits a return to Canada, benefits are limited to the lesser of:
the amount payable under this plan for continued treatment outside Canada, and
the amount payable under this plan for comparable treatment in Canada plus the cost of return transportation.
any further medical care related to a medical emergency after the initial acute phase of treatment. This includes non-emergency continued management of the condition originally treated as an emergency
any subsequent and related episodes during the same absence from Canada
expenses related to pregnancy and delivery, including infant care:
at any time during the pregnancy if the patient’s medical history indicates a higher than normal risk of an early delivery or complications.
expenses incurred more than 6 months after the date of departure from Canada. If you or your dependent is hospital confined at the end of the 6 month period, benefits will be extended to the end of the confinement
Non-emergency care outside Canada is covered for you and your
it is required as a result of a referral from your usual Canadian physician
it is not available in any Canadian province and must be obtained elsewhere for reasons other than waiting lists or scheduling difficulties
you are covered by the government health plan in your home province for a portion of the cost, and
a pre-authorization of benefits is approved by Great-West Life before you leave Canada for treatment.
investigational or experimental treatment
transportation or accommodation charges.
The plan covers the following services and supplies when related to out-of-country care:
diagnostic x-ray and laboratory services
hospital accommodation in a standard or semi-private ward or
intensive care unit, if the confinement begins while you or your dependent is covered
medical supplies provided during a covered hospital confinement
paramedical services provided during a covered hospital
hospital out-patient services and supplies
medical supplies provided out-of-hospital if they would have been
ambulance services by a licensed ambulance company to the nearest centre where essential treatment is available
dental accident treatment if it would have been covered in Canada.
Limitations Except to the extent otherwise required by law, no benefits are paid for:
Expenses private insurers are not permitted to cover by law
Services or supplies for which a charge is made only because you
The portion of the expense for services or supplies that is payable
by the government health plan in your home province, whether or not you are actually covered under the government health plan
Any portion of services or supplies which you are entitled to receive,
or for which you are entitled to a benefit or reimbursement, by law or under a plan that is legislated, funded, or administered in whole or in part by a government (“government plan”), without regard to whether coverage would have otherwise been available under this plan
In this limitation, government plan does not include a group plan for government employees
Services or supplies that do not represent reasonable treatment
Services or supplies associated with:
treatment performed only for cosmetic purposes
recreation or sports rather than with other daily living activities
the diagnosis or treatment of infertility, other than drugs
contraception, other than oral contraceptives and intrauterine devices (IUDs)
Services or supplies not listed as covered expenses
Extra medical supplies that are spares or alternates
Services or supplies received outside Canada except as listed under
Out-of-Country Care and Global Medical Assistance
Services or supplies received out-of-province in Canada unless you
are covered by the government health plan in your home province and Great-West Life would have paid benefits for the same services or supplies if they had been received in your home province
This limitation does not apply to Global Medical Assistance
Expenses arising from war, insurrection, or voluntary participation in
Visioncare services and supplies required by an employer as a
In addition under the prescription drug coverage, no benefits are paid for:
Atomizers, appliances, prosthetic devices, colostomy supplies, first
aid supplies, diagnostic supplies or testing equipment
Non-disposable insulin delivery devices or spring loaded devices
Delivery or extension devices for inhaled medications
Oral vitamins, minerals, dietary supplements, homeopathic
preparations, infant formulas or injectable total parenteral nutrition solutions
Diaphragms, condoms, contraceptive jellies, foams, sponges,
suppositories, contraceptive implants or appliances
Any drug that does not have a drug identification number as defined
Any single purchase of drugs which would not reasonably be used
within 34 days. In the case of certain maintenance drugs, a 100-day supply will be covered
Drugs dispensed by a dentist or clinic or by a non-accredited
Drugs administered during treatment in an emergency room of a
hospital, or as an in-patient in a hospital
Preventative immunization vaccines and toxoids
Drugs that are considered cosmetic, such as topical minoxidil or
sunscreens, whether or not prescribed for a medical reason
Drugs used to treat erectile dysfunction
How to Make a Claim
Out-of-country claims (other than those for Global Medical
Assistance expenses) should be submitted to Great-West Life as soon as possible after the expense is incurred. It is very important that you send your claims to the Great-West Life Out-of-Country Claims Department immediately as your Provincial Medical Plan has very strict time limitations.
Access GroupNet for Plan Members to obtain a personalized claim form or obtain form M5432 (Statement of Claim Out-of-Country Expenses form) from your employer. Unless you are a resident of the Territories you must also obtain the Government Assignment form, and residents of British Columbia, Quebec and Newfoundland & Labrador must also obtain the Special Government Claim form. The Great-West Life Out-of-Country Claims Department will forward the appropriate government forms to your attention when required.
If you are a resident of the Territories, you must submit your out-of-country claims to your territorial government for processing before submitting the claim to Great-West Life. When you receive your Explanation of Benefits back from the territory, please send the following to the Great-West Life Out-of-Country Claims Department (be sure to keep copies for your own records): -
a copy of the payment from your territory
a completed Statement of Claim Out-of-Country Expenses form (form M5432)
Residents of the provinces should complete all applicable forms, making sure all required information is included. Attach all original receipts and forward the claim to the Great-West Life Out-of-Country Claims Department. Be sure to keep a copy for your own records. The plan will pay all eligible claims including your Provincial Medical Plan portion. Your Provincial Medical Plan will then reimburse the plan for the government’s share of the expenses.
Out-of-country claims must be submitted within a certain time period that varies by province. For the claims submission period applicable in your province or territory or for any other questions or for assistance in completing any of the forms, please contact Great-West Life’s Out-of-Country Claims Department at 1-800-957-9777.
Claims for paramedical services and visioncare may be submitted
online. To use this online service you will need to be registered for GroupNet for Plan Members and signed up for direct deposit of claim payments with eDetails. For online claim submissions, your Explanation of Benefits will only be available online.
Claims must be submitted to Great-West Life as soon as possible, but no later than 15 months after you incur the expense. You must retain your receipt for 12 months from the date you submit your claim to Great-West Life as a record of the transaction, and you must submit it to Great-West Life on request.
For Healthcare claims not submitted online, access GroupNet for
Plan Members to obtain a personalized claim form or obtain form M635D from your employer. Complete this form making sure it shows all required information.
Attach your receipts to the claim form and return it to the Great-West Life Benefit Payment Office as soon as possible, but no later than 15 months after you incur the expense.
For drug claims, your employer will provide you with a prescription
drug identification card. Present your card to the pharmacist with your prescription.
Before your prescription is filled, an Assure Claims check will be done. Assure Claims is a series of seven checks that are electronically done on your drug claim history for increased safety and compliance monitoring. This has been designed to improve the health and quality of life for you and your dependents. Checks done include drug interaction, therapeutic duplication and duration of therapy, allowing the pharmacist to react prior to the drug being dispensed. Depending on the outcome of the checks, the pharmacist may refuse to dispense the prescribed drug. When your coverage ends, return your direct pay drug identification card to your employer.
PREFERRED VISION SERVICES (PVS)
Preferred Vision Services (PVS) is a service provided by Great- West Life to its customers through PVS which is a preferred provider network company.
PVS entitles you to a discount on a wide selection of quality eyewear and lens extras (scratch guarding, tints, etc.) when you purchase these items from a PVS network optician or optometrist. A discount on laser eye surgery can be obtained through an organization that is part of the PVS network. PVS also entitles you to a discount on hearing aids (batteries, tubing, ear molds, etc.) when you purchase these items from a PVS network provider. You are eligible to receive the PVS discount through the network whether or not you are enrolled for the healthcare coverage described in this booklet. You can use the PVS network as often as you wish for yourself and your dependents. Using PVS: Call PVS Information Hotline at 1-800-668-6444 or visit the PVS Web site at www.pvs.ca for information about PVS locations and the program
Arrange for a fitting, an eye examination, a hearing assessment or a
Present your group benefit plan identification card, to identify your
preferred status as a PVS member through Great-West Life, at the time the eyewear or the hearing aid is purchased, or at the initial consultation for laser eye surgery
Pay the reduced PVS price. If you have vision care coverage or
hearing aids coverage for the product or service, obtain a receipt and submit it with a claim form to your insurance carrier in the usual manner.
A deductible may be applied before you are reimbursed. All expenses will be reimbursed at the level shown in the Benefit Summary. Benefits may be subject to plan maximums and frequency limits. Check the Benefit Summary for this information. The plan covers customary charges to the extent they do not exceed the dental fee guide level shown in the Benefit Summary. Denturist fee guides are applicable when services are provided by a denturist. Dental hygienist fee guides are applicable when services are provided by a dental hygienist practising independently. All covered services and supplies must represent reasonable treatment. Treatment is considered reasonable if it is recognized by the Canadian Dental Association, it is proven to be effective, and it is of a form, frequency, and duration essential to the management of the person's dental health. To be considered reasonable, treatment must also be performed by a dentist or under a dentist’s supervision, performed by a dental hygienist entitled by law to practise independently, or performed by a denturist. Treatment Plan
Before incurring any large dental expenses, or beginning any
orthodontic treatment, ask your dental service provider to complete a treatment plan and submit it to Great-West Life. Great-West Life will calculate the benefits payable for the proposed treatment, so you will know in advance the approximate portion of the cost you will have to pay.
Basic Coverage The following expenses will be covered:
one complete oral examination every 36 months
limited oral examinations once every 9 months, except that only one limited oral examination is covered in any 12-month period that a complete oral examination is also performed
limited periodontal examinations once every 9 months
complete series of x-rays every 36 months
intra-oral x-rays to a maximum of 15 films every 36 months and a panoramic x-ray every 36 months. Services provided in the same 12 months as a complete series are not covered
polishing and topical application of fluoride each once every 9 months
scaling, limited to a maximum combined with periodontal root planing of 10 time units every 12 months
A time unit is considered to be a 15-minute interval or any portion of a 15-minute interval
pit and fissure sealants on bicuspids and permanent molars every 60 months
space maintainers including appliances for the control of harmful habits
Minor restorative services including:
amalgam and tooth-coloured fillings. Replacement fillings are covered only if the existing filling is at least 2 years old or the existing filling was not covered under this plan
retentive pins and prefabricated posts for fillings
Endodontics. Root canal therapy for permanent teeth will be limited
to one course of treatment per tooth. Repeat treatment is covered only if the original treatment fails after the first 18 months
root planing, limited to a maximum combined with preventive scaling of 10 time units every 12 months
occlusal adjustment and equilibration, limited to a combined maximum of 4 time units every 12 months
A time unit is considered to be a 15-minute interval or any portion of a 15-minute interval
Denture maintenance, after the 3-month post-insertion care period,
denture relines for dentures at least 6 months old, once every 36 months
denture rebases for dentures at least 2 years old, once every 36 months
resilient liner in relined or rebased dentures, once every 36 months
denture repairs and additions and resetting of denture teeth
denture adjustments, once every 12 months
Crowns. Coverage for crowns on molars is limited to the cost of
metal crowns. Coverage for complicated crowns is limited to the cost of standard crowns
Onlays. Coverage for tooth-coloured onlays on molars is limited to
Replacement crowns and onlays are covered when the existing restoration is at least 5 years old and cannot be made serviceable
Standard complete dentures, standard cast or acrylic partial
dentures or complete overdentures or bridgework when required to replace one or more teeth extracted while the person is covered. Overdentures and bridgework are covered only when standard complete or partial dentures are not viable treatment options. Coverage for tooth-coloured retainers and pontics on molars is limited to the cost of metal retainers and pontics. Replacement appliances are covered only when:
the existing appliance is a covered temporary appliance
the existing appliance is at least 5 years old and cannot be made serviceable. If the existing appliance is less than 5 years old, a replacement will still be covered if the existing appliance becomes unserviceable while the person is covered and as a result of the placement of an initial opposing appliance or the extraction of additional teeth.
If additional teeth are extracted but the existing appliance can be made serviceable, coverage is limited to the replacement of the additional teeth
Denture-related surgical services for remodelling and recontouring
Denture and bridgework maintenance following the 3-month post-
Orthodontics are covered for persons age 6 or over when treatment
Limitations No benefits are paid for: Duplicate x-rays, custom fluoride appliances, any oral hygiene
The following endodontic services - root canal therapy for primary
teeth, isolation of teeth, enlargement of pulp chambers and endosseous intra coronal implants
The following periodontal services - desensitization, topical
application of antimicrobial agents, subgingival periodontal irrigation, charges for post surgical treatment and periodontal re-evaluations
The following oral surgery services - implantology, surgical
movement of teeth, services performed to remodel or recontour oral tissues (other than minor alveoloplasty, gingivoplasty and stomatoplasty) and alveoloplasty or gingivoplasty performed in conjunction with extractions. Services for remodelling and recontouring oral tissues will be covered under Major Coverage
Veneers, recontouring existing crowns, and staining porcelain
Crowns or onlays if the tooth could have been restored using other
procedures. If crowns, onlays or inlays are provided, benefits will be based on coverage for fillings
Overdentures or initial bridgework if provided when standard
complete or partial dentures would have been a viable treatment option.
If overdentures are provided, coverage will be limited to standard complete dentures.
If initial bridgework is provided, coverage will be limited to a standard cast partial denture and restoration of abutment teeth when required for purposes other than bridgework
If additional bridgework is performed in the same arch within 60 months, coverage will be limited to the addition of teeth to a denture and restoration of abutment teeth when required for purposes other than bridgework
Benefits will be limited to standard dentures or bridgework when equilibrated and gnathological dentures, dentures with stress breaker, precision and semi-precision attachments, dentures with swing lock connectors, partial overdentures and dentures and bridgework related to implants are provided
Expenses covered under another group plan's extension of benefits
Services or supplies covered under Healthcare. If the amount
payable would be greater under this Dentalcare benefit, then benefits will be paid under Dentalcare and not Healthcare
Expenses private plans are not permitted to cover by law
Services and supplies you are entitled to without charge by law or
for which a charge is made only because you have insurance coverage
Services or supplies that do not represent reasonable treatment
Treatment performed for cosmetic purposes only
Congenital defects or developmental malformations in people 19
years of age or over, except orthodontics
Temporomandibular joint disorders, vertical dimension correction or
Expenses arising from war, insurrection, or voluntary participation in
How to Make a Claim For dentalcare claims submitted online, access GroupNet for Plan
Members to obtain a personalized claim form or obtain a copy of form M445D from your employer and have your dental service provider complete the form. The completed claim form will contain the information necessary to enter the claim online. To use the online service you will need to be registered for GroupNet for Plan Members and signed up for direct deposit of claim payments with eDetails. For online claim submissions, your Explanation of Benefits will only be available online.
Claims must be submitted to Great-West Life as soon as possible, but no later than 15 months after the dental treatment.
You must retain your receipt for 12 months from the date you submit your claim to Great-West Life as a record of the transaction, and you must submit it to Great-West Life on request.
For dentalcare claims not submitted online, access GroupNet for
Plan Members to obtain a personalized claim form or obtain form M445D from your employer. Have your dental service provider complete the form and return it to the Great-West Life Benefit Payment Office as soon as possible, but no later than 15 months after the dental treatment.
COORDINATION OF BENEFITS
Benefits for you or a dependent will be directly reduced by any
amount payable under a government plan. If you or a dependent are entitled to benefits for the same expenses under another group plan or as both an employee and dependent under this plan or as a dependent of both parents under this plan, benefits will be co-ordinated so that the total benefits from all plans will not exceed expenses.
You and your spouse should first submit your own claims through
your own group plan. Claims for dependent children should be submitted to the plan of the parent who has the earlier birth date in the calendar year (the year of birth is not considered). If you are separated or divorced, the plan which will pay benefits for your children will be determined in the following order:
1. the plan of the parent with custody of the child; 2. the plan of the spouse of the parent with custody of the child; 3. the plan of the parent without custody of the child; 4. the plan of the spouse of the parent without custody of the child
You may submit a claim to the plan of the other spouse for any amount which is not paid by the first plan.
DIAGNOSTIC AND TREATMENT SUPPORT SERVICES (BEST DOCTORS® SERVICE)
This service is designed to allow you, your dependents and your attending physician or specialists access to the expertise of world-class specialists, resources, information and clinical guidance. If you or your dependents are diagnosed with a serious medical condition for which there is objective evidence, or if your physician or you or your dependent suspect you have this condition, you can access this service. This service is made up of a unique step-by-step process that may help address questions or concerns about a medical condition. This may include confirming the diagnosis and suggesting the most effective treatment plan by drawing on a global database of up to 50,000 peer-ranked specialists. How it works
You or your dependent can access diagnostic and treatment support
services by calling 1-877-419-BEST (2378) toll-free.
You will be connected with a member advocate who will be
dedicated to your case and will provide support through the process. The member advocate will take the necessary medical history and answer your questions. Any information provided is not shared with either your employer or the administrator of your health plan.
Based on the information and questions, the member advocate
determines the optimal level of service for you or your dependent.
The member advocate may provide information, resources,
guidance and advice individually tailored to meet your health needs. They can also help identify individual community supports and resources available.
If it is appropriate, the member advocate may arrange for an in-
depth review of your medical file to assist in confirming the diagnosis and help develop a treatment plan. This review may include collecting, deconstructing and reconstructing medical records, pathology retesting and analyzing test results. A written report outlining the conclusions and recommendations of the specialists will be forwarded to you and your physician. On average, this process takes 6 to 8 weeks. Timeframes may vary depending on the complexity of the case and amount of medical records to collect.
If you decide to seek treatment by a different physician, the member
advocate can help identify the specialist best qualified to meet your specific medical needs. Expenses incurred for travel and treatment are not covered by this service.
If you decide to seek treatment outside Canada, the member
advocate can arrange referrals and can help book accommodations. The member advocate can also access hospital and physician discounts, arrange for forwarding of medical information and monitor the treatment process. Expenses incurred for travel and treatment are not covered by this service.
Note: These services are not insured services. Great-West Life is not responsible for the provision of the services, their results, or any treatment received or requested in connection with the services.
Antimicrobial Resistance Trends Among Sinus Isolates of Streptococcus pneumoniae from the Contact Information: United States: 2000 – 2005 Daniel Sahm, Ph.D. Focus Bio-Inova Inc. Poster #495 Deborah Draghi1, Alan T. Evangelista2, Y. Cheung Yee2, Robert K. Flamm1, Mark E. Jones1, Clyde Thornsberry1, Daniel F. Sahm1 Herndon, VA, USA 1Focus Bio-Inova, Inc., Herndon, VA;2Janss
BULLETIN NUMÉRO 1 U n e c a m p a g n e d ' i n f o r m a t i o n s u r l ' a s s u r a n c e m é d i c a m e n t s En tant que consommateurs, nous avons beaucoup plus de contrôle sur les coûts que nous le pensons et nous pouvons adopter de nouveaux comportements pour mieux gérer nos dépenses de médicaments. Saviez-vous qu’en vertu d'ententes, certains médicaments généri