Eligible dependents, and pensioners



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HEALTH AND DENTAL BENEFITS
FOR
MEMBERS OF THE POWER WORKERS' UNION

(CUPE LOCAL 1000),
ELIGIBLE DEPENDENTS,
AND PENSIONERS

Effective April 1, 2014

Green Shield Canada Billing Divisions:

100 Active, 500 LTD, 600 Pensioner




TABLE OF CONTENTS


YOUR BENEFITS AT A GLANCE 4

Section 1.0 OVERVIEW 5

Section 2.0 RESPONSIBILITIES 6

Section 2.1 EMPLOYEES AND PENSIONERS 6

7

Section 2.2 GREEN SHIELD CANADA (herein referred to as ‘the carrier’) 7



Section 3.0 WHO IS COVERED? 7

Section 4.0 DEFINITIONS 8

Section 5.0 PROCESS FOR SUBMITTING CLAIMS 8

Section 6.0 RIGHT OF RECOVERY 9

Section 7.0 CO-ORDINATION OF BENEFITS 9

Section 7.1 RIGHT TO RELEASE AND RECEIVE NECESSARY INFORMATION 9



Section 8.0 ANNUAL DEDUCTIBLE 9

Section 9.0 REASONABLE & CUSTOMARY SERVICES 10

Section 10.0 EXCLUDED CHARGES 10

Section 11.0 SEMI PRIVATE AND PRIVATE HOSPITAL ROOMS 11

Section 12.0 THE COMPANY’S DRUG PLAN 11

Section 13.0 ONTARIO DRUG BENEFIT (ODB) PLAN 12

Section 14.0 EXTENDED HEALTH BENEFITS PLAN 12

Section 15.0 DENTAL BENEFITS (excluding orthodontic benefits) 17

Section 16.0 ORTHODONTIC BENEFITS 18

Section 17.0 LIMITATIONS ON BENEFITS OUTSIDE ONTARIO 20

Section 17.1 Extended Health Benefits Plan 20

Section 17.2 Dental Plan 20

Section 17.3 Reimbursement of Claims outside of Canada 20



Section 18.0 BENEFITS COVERAGE FOR EMPLOYEES WORKING OUTSIDE ONTARIO 20

Section 18.1 OHIP Coverage 20

Section 18.2 Health & Dental Benefits 20

Section 18.3 WSIB Compensation 21



Section 19.0 OHIP COVERAGE FOR PENSIONERS 21

APPENDIX 22

LIST OF DENTAL SERVICES 22



This brochure provides an overview of the Health and Dental benefits program, as well as other government programs for employees represented by the Power Worker’s Union. While every effort has been made to ensure that this information is clear and accurate, this brochure does not cover every aspect of these programs in detail. If neither this brochure nor the collective agreement covers a specific situation, ESA reserves its right to govern itself in accordance with the relevant plan documents, while the Union reserves its rights under the collective agreement. This brochure replaces the previous ESA brochure entitled Health and Dental Benefits for Members of the Power Workers’ Union (CUPE Local 1000), Eligible Dependents and Pensioners, Effective April 1, 2011 to further clarify certain benefit provisions, as well as reflect the benefit provisions set out in the Memorandum of Agreement between ESA and the Power Worker’s Union dated April 1, 2014.
For more information, please contact Human Resources or visit our intranet website at http://esaintranet/ and select “Human Resources and Payroll”.

Prepared by ESA Human Resources – April 2014



YOUR BENEFITS AT A GLANCE





Your Plan Covers:

Your Co-Pay:

Maximum Plan Pays:

Prescription Drugs – Pay Direct Drug Card


    • Over the counter products; limited access drugs, natural health products, smoking cessation products (including patches, lozenges and gums)

  • All other covered drugs (including prescription smoking cessation drugs)

Equal to any allowed dispensing or compounding fees per prescription or refill


Nil





  • Fertility drugs




A 12 months supply or $5,000 per lifetime, whichever occurs first

  • Erectile dysfunction drugs




$500 per calendar year

  • Smoking cessation drugs and products




$1,000 per calendar year combined

  • All other covered drugs




Unlimited

Hospital Accommodation

0%




  • Public general - semi-private or private room




Reasonable and customary charges

  • Convalescent or rehabilitation hospital or licensed private hospital- semi-private room or private room




$20 per day up to 120 days per lifetime combined


  • Public chronic hospital - semi-private room or private




$30 per day up to 120 days per 365 consecutive days


Hearing Aids (Audio)


0%

One hearing aid of any type per ear every 3 years , limited to the Reasonable and Customary charges for a standard hearing aid

Medical Items and Services







Footwear

0%




  • custom made boots or shoes and adjustments to stock item footwear




2 pairs per calendar year combined


  • custom made foot orthotics




1 pair every 3 calendar years up to $450 (per calendar year for covered persons 18 years of age and under)

  • Back rest (Orthopedic Surgeon or Chiropractor recommendation required)

0%

1 every 5 years based on date of first paid claim

  • Blood glucose monitor

0%

1 every 3 calendar years

  • Blood pressure monitor

0%

1 every 3 years based on date of first paid claim

  • Breast prosthesis

0%

1 of any kind every 2 years based on date of first paid claim

  • Bra (mastectomy)

0%

3 every 12 months based on date of first paid claim

  • Cervical pillow

0%

1 every 12 months based on date of first paid claim

  • Insulin gun (manual/automatic)

0%

1 of each kind every 3 calendar years


  • Insulin pump

0%

1 every 3 calendar years


  • Insulin pen injector

0%

1 every 3 calendar years


0%

1 every 3 years based on date of first paid claim

0%

Once per calendar year

  • Compression stockings

0%

3 pairs every 12 months based on date of first paid claim

  • Synvisc Injections (Viscosupplementation)

0%

$3,000 per lifetime


  • Wigs

0%

$500 every 3 calendar years

  • Food supplements – Nutramigen for children and Ensure for adults when prescribed by a physician

15%

Reasonable and customary charges


0%

Reasonable and customary charges

Emergency Transportation

0%

Reasonable and customary charges

Private Duty Nursing in the Home

0%

Reasonable and customary charges

Professional Services







  • Chiropractor

0%

$650 per calendar year, increases to $700 per calendar year effective April 1, 2016

  • Chiropodist or Podiatrist

0%

$200 per calendar year

  • Acupuncturist

  • Registered Massage Therapist and Shiatsu Therapist (Physician (M.D.) recommendation required)

  • Homeopath

  • Naturopath

50%

$700 for all practitioners combined per calendar year

  • Physiotherapist

0%

Reasonable and customary charges

  • Psychologist

0%

$2,500 per calendar year

  • Speech Therapist

  • (Physician (M.D.) or Dentist recommendation required)

0%

$300 per calendar year

Accidental Dental

0%

Reasonable and customary charges

Vision







  • Prescription eye glasses or contact lenses, or medically necessary contact lenses, or cataract eyewear




$550 every 2 calendar years, increases to $600 every 2 calendar years effective April 1, 2015

  • Annual eye exams




Once per calendar year

  • Laser eye surgery (Radial Kerototony/Laser Keratectomy)




$3,000 per lifetime

Dental Services







Basic Services and Comprehensive Basic Services

0%


Unlimited

Major Services

25%

Unlimited

Orthodontic Services


25%

$4,000 per covered person per lifetime

Effective April 1, 2013:

$4,500 per covered person per lifetime



TMJ Appliances

25%

$1,300 per covered person per lifetime






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