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This booklet contains information about your Group Benefits. Please keep it in a safe place. It is intended to summarize the principal features of your plan. All rights to benefits are governed by the Group Defined terms are capitalized (e.g. Dependent). Pacific Blue Cross (PBC) is referred to as “we”, “us”, or “our” in this booklet. We will refer to you, the employee/member, as “you” or “your” in this booklet. Pacific Blue Cross, the registered trade-name of PBC Health Benefits Society, is an independent licensee of the Canadian Association of Blue Please refer to the Table of Contents to help you locate the appropriate section in this booklet. If you require additional information, please We have a Privacy Policy which governs our collection, use, and disclosure of personal information (including personal health information) about individuals who are members or Dependents. The Privacy Policy requires us to keep such personal information confidential, but does permit use and disclosure of personal information in limited circumstances consistent with the proper administration of group benefit and insurance coverage plans. A copy of our current Privacy Policy can be obtained from us on request and is also available on our website: www.pac.bluecross.ca. By participating in the group benefit and insurance plans, and submitting claims under those plans, you are consenting to the collection, use, and disclosure of your personal information pursuant to the terms of our ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,# ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, % ) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, / Effective Date of Coverage and Enrolment . 11 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, #' Out-of-Province Non-Emergency Eligible Expenses . 23 Out-of-Province Emergency Eligible Expenses . 23 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, %( Plan A – Basic Preventive & Restorative Services. 28 Plan B – Major Restorative Services . 30 Emergency Treatment Outside Your Province of Residence . 32 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, The Schedule of Benefits contains a brief summary of your benefits. Please refer to the appropriate page in this booklet for a more detailed $25 per person or family each calendar year. If in any calendar year the Eligible expenses do not exceed the Deductible, the Eligible expenses incurred during the last 3 months of the calendar year may be applied against the After $1,000 has been paid for a person or family in a calendar year, further Eligible expenses for that person or family within that year will be reimbursed at 100%, subject to Dependent Children See definition of Dependent. means within 4 months from the coverage effective date. means the date coverage becomes effective based on 2) the average number of hours you work each week or each year, 3) the waiting period selected by your employer, and means the initial portion of the Eligible expenses, which you must pay before we will reimburse charges for any Eligible expense. means a doctor of dentistry who is duly qualified and licensed to practice dentistry in the area where the service is provided. For the purposes of this booklet, Dentist may also mean dental specialist, or means any of the following persons for whom coverage is provided 2) an unmarried child of the Member or Spouse who: i) is under age 21, is fully dependent on the Member and Spouse ii) is any age as a full-time student attending a recognized school, college or university and is fully dependent on the Member iii) is any age as a mentally or physically handicapped person, is fully dependent on the Member and Spouse for support and means that you (and your Dependents) are eligible to claim certain means the Canadian provincial/territorial dental Fee guide that contains dental services and fees in effect on the date the dental services are performed. For Alberta, the Fee guide means the current Alberta Blue means Schedule 2 of the Pacific Blue Cross Fee schedule that contains eligible dental services, financial limits, treatment frequencies, and fees in effect on the date the dental services are performed. -means your legal Spouse or a person who has been living with you in a common-law relationship for at least 6 consecutive months and who is Extended health care benefits are intended to supplement and not overlap benefits under government plans such as the Medical Services Plan and Fair PharmaCare Program of British Columbia. You are required, as a condition of coverage, to take all reasonable steps to qualify and obtain the fullest extent of coverage, benefits, contribution, or reimbursement available under all applicable government plans. We will also make payment only where permitted by provincial legislation If you are eligible for coverage, you must complete an application card within the Allowable enrolment period to ensure that your coverage You should apply for Dependent coverage (when applicable): 1) on the same date you apply for your own coverage, or 2) within the Allowable enrolment period if you have a new 1) If you are not actively at work on your coverage effective date, your coverage effective date will be delayed until you return to 2) If we do not receive your application card within the required time limits, please refer to the Late Applicant section. Coverage begins on the coverage effective date shown on your identification (ID) card(s), provided you and your Plan Administrator Should you require additional information about when your coverage starts, please contact your Plan Administrator. If you did not apply during the Allowable enrolment period but request coverage later (for yourself and/or your Dependents), ask your Plan Administrator to explain the requirements for late enrolment in your Group Plan. Note: Different benefits may have different requirements – health evidence or retroactive premium payment. In some instances, We will issue identification (ID) cards for distribution by your Plan Only you and your enrolled Dependents are entitled to use this card. Should you (or your Dependent) allow an ineligible person to use this card, your coverage may be suspended without notice. You may be asked to substantiate that an individual you claim as a Dependent meets the definition of Dependent for your group. 1) All claims must be submitted to us in English. 2) We pay eligible claims when we receive all the required become familiar with the time periods allowed for claiming benefits. Under the Claims sections, we fully describe the claiming deadlines for each benefit. No payment will be made if we receive your claim after the time limits described in this 3) We may reject your claim if sufficient information is not provided to enable a full assessment of the claim, or if an attempt is made, except through unintentional error, to make an excessive claim, or if a claim is made for a person who is not entitled. 4) The necessary claim forms are available from your Plan 5) The exchange rate on foreign currency is payable at the rate quoted by selected Canadian financial institutions for the date on which the expense was paid. Fluctuations in exchange rates are not our If you and your Spouse work for the same employer, please check with your Plan Administrator to see if Duplicate coverage is allowed for dental and extended health care benefits. If you and your Spouse work for different employers and you are both enrolled for similar benefits, Duplicate coverage is allowed. If you are eligible for Duplicate coverage, you and your family should discuss both plans (and what portion of the benefits you pay) to determine whether it is to your advantage to enroll under more than one Your Plan Administrator will advise you if you are eligible to waive If Duplicate coverage is allowed, we pay claims based on the rules of the Canadian Life and Health Insurance Association guidelines. They 1) Dependent 00 is always the primary claimant. Dependent 01 (or 90 to 99) is always the secondary claimant. 2) Dependent children are always covered primarily under the parent who has the earliest birthdate in the year (month and day). 3) In situations of separation or divorce, the following order applies: a) the plan of the parent with custody of the child b) the plan of the Spouse of the parent with custody of the child c) the plan of the parent not having custody of the child d) the plan of the Spouse of the parent in c) above. 4) Total reimbursement shall never exceed 100% of the Eligible 1) We will not be liable for any portion of an expense for which you or your Dependent is entitled to reimbursement: a) under any other group or individual benefit plan or insurance b) due to the legal liability of any other party. 2) In no event will benefits be payable for expenses resulting directly or indirectly from, or in any manner or degree associated with, any a) intentional self-inflicted injury while sane or insane, war, whether declared or undeclared, or any act of war, or participation in a riot, insurrection, or civil commotion b) active duty in the military forces of any nation or international organization, or in any civilian noncombatant unit which c) a direct or indirect attempt at, or commission of, an indictable offense under the Criminal Code of Canada or similar law of d) false pretences or fraudulent misrepresentation e) any injury, illness, or condition for which care is provided or may be provided or available without cost by public authorities or by a tax-supported agency, including preventive treatment and services available under any Workers' Generally, your coverage (and any Dependent coverage) terminates if you cease to be eligible due to change of group, leave of absence, age limitation or retirement, if you terminate your employment, or if the group plan terminates, etc. For further details on termination of coverage, please have your Plan Administrator refer to the Group Should your group coverage terminate for any reason, you may purchase an individual plan from Pacific Blue Cross if you live in British Columbia, or an individual plan offered by your local Blue Cross organization if you live elsewhere in Canada. To convert coverage you must ensure that your application and full payment is received by us or Blue Cross within 60 days of the date your group plan terminates. Coverage will become effective immediately after your group coverage terminates. If you qualify for one of our individual plans under the conversion option, we will waive the Preexisting condition contained in the means any illness or condition for which you receive medical attention, consultation, diagnosis, or treatment in the 12 month period before you Call our Individual Products Department at 604 419-2200 for an If you are converting to an individual plan offered by Blue Cross, contact your local Blue Cross organization for full details before your Individual coverage is also available from us. Call 604 419-2200 or 1 800 USE-BLUE (873-2583) outside the Lower Mainland for CARESnet is an online service from Pacific Blue Cross that offers you convenient and secure access to your benefit information 24 hours a day. Information about benefit coverage, claim status, and easy access to claim forms are the enhanced services CARESnet provides. To access CARESnet, visit our website: .
The Extended Health Care (EHC) plan is designed to help you pay for specified services and supplies incurred by you and your Dependents, when not provided under a government health plan or by a tax- All dollar limits included in the benefit descriptions are & • calculates the total Eligible expense • subtracts the Deductible, when applicable • applies the reimbursement percentage • calculates the total Eligible expense • subtracts the Deductible, when applicable • applies the reimbursement percentage means a charge for any service and/or supply included in this booklet 1) in our assessment is a customary charge medically necessary for health care and maintenance, or to maintain or restore teeth, and 2) was ordered or referred by a Physician or Dentist, unless otherwise specified in the benefit description, and 3) is not a cost normally paid (in whole or part) or provided by a government plan or any other provider of health coverage, and 4) is incurred while your coverage is valid. An expense is "incurred" on the date the service is provided or the supply is received. It does not include any payment to a pharmacy or a Practitioner (demanded or received by balanced billing, extra billing, or extra charging) which represents an amount in excess of the schedule of costs prescribed by the government plan. PharmaCare’s low cost alternative and reference based pricing will not be applied unless specified in this means an individual who is duly qualified and licensed to practice medicine or surgery, or both, in the area where the service is provided, but excludes a Physician residing with or related to you or your means an individual who is currently licensed, certified, or registered to practice a profession in the area where the care or service is provided. Your EHC plan covers reasonable and customary charges for the following services and supplies when medically necessary, and prescribed, ordered, or referred by a Physician. Unless otherwise indicated, the maximums included here are on a per person basis. The additional charge for semi-private or private room accommodation in a hospital or the extended care unit of a hospital. Charges for rental of a telephone, television, or similar a) charges for licensed ambulance service to and from the nearest Canadian hospital equipped to provide the type of care b) air transport will be covered when time is critical and the patient's physical condition prevents the use of another means c) emergency transport from one hospital to another, only when the original hospital has inadequate facilities d) charges for an attendant when medically necessary. Drugs and medicines dispensed by a licensed pharmacist or a Physician, in a quantity we consider reasonable: a) drugs and medicines which legally require a prescription from a Physician or Dentist, and included with the above: b) insulin preparations, testing supplies, needles, and syringes for c) vitamin B12 for the treatment of pernicious anemia d) allergy serums when administered by a Physician. Drugs and medicines which are not covered by Pharmacare but which are currently covered under this Plan will continue to be covered. Reimbursement of eligible drugs and medicines will be subject to Pharmacare's low cost alternative and reference based pricing payment policies. If the drug or medicine does not meet the patient's needs, Pharmacare's low cost alternative and reference based pricing will not apply. A doctor's letter indicating this must Professional services of the following Practitioners to the maximum amounts indicated per calendar year, but excluding appliances and tray fees. Only the services of a private duty nurse require referral by a Physician. a) acupuncturist .$500 h) private duty care by a registered nurse for a person with an acute condition in the person’s home or in a hospital in the Dental treatment by a Dentist, which is required, performed, and completed within 52 weeks after an Accidental injury which occurred while covered under this EHC plan, for the repair or replacement of natural teeth or prosthetics. No payment will be made for temporary, duplicate, or incomplete procedures, or for correcting unsuccessful procedures. "&&means caused by a direct external blow to the mouth or face resulting in immediate damage to the natural teeth or prosthetics and not by an object intentionally or unintentionally being placed We pay benefits based on eligible dental services and financial limits in our current Fee schedule, and we pay the fees in our current Fee schedule or, if applicable, the Fee guide in the Charges for the following services and supplies: c) walkers, canes and cane tips, crutches, splints, casts, collars, and trusses, but not elastic or foam supports d) rigid support braces and permanent prostheses (artificial eyes, limbs, larynxes, and mastectomy forms). Myoelectrical limbs are excluded, but we will pay the equivalent of a standard e) mastectomy brassieres to a maximum of 1 brassiere per breast f) charges for the following items to the limitation and maximum g) wigs and hairpieces required as a result of medical treatment, injury, alopecia areata, alopecia universalis or alopecia totalis i) custom made orthopedic shoes (including repairs) and modifications to stock item footwear when prescribed by a Physician, podiatrist, or chiropractor as medically necessary after diagnosis of the patient. A custom made orthopedic shoe is one fabricated from raw materials and specifically designed for the patient, based on a three- dimensional volumetric model of the patient’s foot and ii) custom made orthotics when prescribed by a Physician, podiatrist, chiropractor, or physiotherapist as medically necessary after diagnosis (including an in person biomechanical assessment) of the patient. A custom made orthotic is one fabricated from raw materials using a three- dimensional volumetric model of the patient’s feet to a combined limit of one pair for an adult and Dependent child i) hearing aids (including repairs, maintenance, batteries, recharging devices, or other such accessories) to a maximum of $1,000 in a 60 month period per ear per person. Replacement will be covered only when the hearing aid cannot be repaired j) hearing protection on a voluntary basis per employee to a payable maximum of $100 in a 60 month period beginning at the date of service of the first claim and must be approved by k) hearing test per employee reimbursed at 80% of the cost up to a maximum of $100 in a 12 month period, subject to a) Preauthorization is required from us for expenses in excess of b) Charges for standard durable medical equipment when rented from a medical supplier. If unavailable on a rental basis, or required for a long-term disability, purchase of these items c) Repairs to purchased items. We will replace the item when it can no longer be made functional. We may request trade-in or d) Reimbursement on rental equipment will be made monthly and will in no case exceed the total purchase price of similar i) manual wheelchairs, manual type hospital beds, and necessary accessories – electric wheelchairs and hospital beds will be covered only when the patient is incapable of operating a manual wheelchair, otherwise we will pay the ii) medical heart and blood glucose monitors, and cardiac iii) bi-osteogen systems (when recommended by an orthopedic surgeon) and growth guidance systems iv) breathing machines and appliances including respirators, compressors, percussors, suction pumps, oxygen v) insulin infusion pumps for diabetics – when basic vi) transcutaneous electric nerve stimulators (TENS) when vii) transcutaneous electric muscle stimulators (TEMS) required when, due to an injury or illness, all muscle tone Charges for the purchase of eyewear when prescribed by a Physician or optometrist and/or repair of eyewear and charges for contact lens fittings when performed by a Physician or optometrist to a maximum of $400 in a 24 month period. Charges for non-prescription eyewear are not covered. Charges of a Physician for medical examinations required by government statute or regulation for employment purposes provided such charges are not payable by your employer under a 10) Prostate Blood Testing for employees over 40 years of age per We will reimburse you (and your Dependents) for non-emergency Eligible expenses incurred while travelling outside your province of residence subject to the Deductible, in-province reimbursement percentage, and maximums. We will not reimburse any expenses payable or provided under a government plan. While travelling outside your province of residence, benefits are payable for the following Eligible expenses incurred IN AN EMERGENCY ONLY and when ordered by the attending Physician. Non-emergency continuing care, testing, treatment, and surgery, and amounts covered by any government plan and/or any other provider of 1) Local ambulance services when immediate transportation is required to the nearest hospital equipped to provide the treatment 2) The hospital room charge and charges for services and supplies when confined as a patient or treated in a hospital, to a maximum If reasonably possible, we should be notified within 5 days of the patient's admission to hospital. When the patient's condition has stabilized, we have the right, with the approval of the attending Physician, to move the patient by licensed ambulance service to the hospital nearest the patient's home which is equipped and has space available to provide further medical treatment. Where transportation would endanger the patient's health, the 90 day limit may be extended with our express written consent. 3) Services of a Physician and laboratory and x-ray services. 4) Prescription drugs in sufficient quantity to alleviate an acute 5) Other emergency services and/or supplies, if we would have covered them inside your province of residence. In emergencies which occur while you (and your Dependents) are travelling, medi-assist will coordinate the following services: 1) locate the nearest appropriate medical care 2) obtain consultative and advisory services and supervision of medical care by qualified licensed Physicians 3) investigate, arrange and coordinate medical evacuations and 4) arrange and coordinate the repatriation of remains 5) replace lost or stolen passports, locate qualified legal assistance and local interpreters, and other incidental aid you and/or your Your Pacific Blue Cross worldwide emergency medi-assist card provides instant information on how to contact medi-assist. Call the nearest medi-assist emergency access number listed on your card. If necessary, call collect or contact the local telephone operator for help in placing your call to medi-assist. Have your EHC ID number and medi-assist group number ready for personal identification – both The following are not included as Eligible expenses under your EHC 1) except as specifically included in this booklet: dentures or dental treatments, hearing aids, eyeglasses, contact lenses, surgical lens implants, or examinations for the prescription or fitting of any of these, x-rays, hospital coinsurance, vitamins and/or minerals, contraceptives, fertility drugs, erectile dysfunction drugs, medications used to treat or replace an addiction or habituation, support stockings, orthotics, arch supports, transportation charges incurred for elective treatment and/or diagnostic procedures or for health or health examinations of any kind, and professional services of Physicians or any person who renders a professional health service in the patient's province of residence 2) general anesthetic, medications used to prevent baldness or promote hair growth, food replacements or supplements, HCG injections, drugs not approved for sale and distribution in Canada, and medications available without a prescription 3) any drug, vaccine, item or service classified as preventive treatment or administered for preventive purposes, and which is not specifically required for treatment of an illness or injury 4) allergy testing unless rendered by a naturopath 5) personal comfort items, items purchased for athletic use, air humidifiers and purifiers, services of Victorian Order of Nurses or graduate or licensed practical nurses, services of religious or spiritual healers, occupational therapy, services and supplies for cosmetic purposes, public ward accommodation, rest cures, and 6) charges for completion of forms or written reports, communication costs, delivery and mailing or handling charges, interest or late payment charges, non-sharable or capital costs levied by local hospitals, or charges for translating documents into English 7) any payment to a pharmacy, a Practitioner, or a Physician (demanded or received by balanced billing, extra billing or extra charging) which represents an amount in excess of the schedule of 8) that portion of a claim normally covered by the government plan which has been refused on the basis that the claim was not submitted within the government plan's time limits 9) expenses incurred, outside your province of residence, due to elective treatment and/or diagnostic procedures, or complications 10) expenses incurred, outside your province of residence, due to therapeutic abortion, childbirth, or complications of pregnancy occurring within 2 months of the expected delivery date 11) charges incurred outside your province of residence for continuous or routine medical care normally covered by the government plan 12) expenses of a Dependent hospitalized at the time of enrolment 13) services performed by a Physician who is related to or resident 14) fees for ambulance services when an ambulance is called but not 15) ambulance charges for work related illness or injury assessed by the Workers' Compensation Board to be your employer’s 16) retroactive coverage and payment of any expense, including expenses that receive special authorization from PharmaCare 17) any other item not specifically included as a benefit. Provided your pharmacy is connected to our electronic processing system, we will pay them directly for prescription drugs and testing supplies for diabetics covered under your EHC plan. Simply show the The pharmacist will charge you only for amounts not covered by us. If you or the pharmacy do not have access to this system, or for other types of expenses, please follow the instructions below. ! If your Spouse and/or children have coverage through another plan, your Pay Direct card cannot be used for their prescription expenses. Please refer to item 2 below for further information. 1) Because we do not return receipts after the claim is processed, we suggest that you keep a photocopy of the receipts that you submit to us. We will send you a remittance statement for your records 2) If you have Duplicate coverage, please review the Coordination of Benefits section under General Information. Two separate claim forms (one for the primary plan and one for the secondary plan) must be completed. The remittance statement from the first plan must be submitted to the second plan. Because claims information regarding the other plan is not retained on our files, be sure to provide information on the second plan on both claim forms. Incomplete claims will be returned for clarification. 3) Certain medical expenses are covered under the government plan. If you submit your claim to us before you submit your claim to the government plan, we will deduct what the government plan would normally pay (e.g. PharmaCare expenses) from your EHC claim. The balance of the EHC claim is then paid according to the plan design selected by your employer. Information for claiming PharmaCare expenses may be obtained from your pharmacist. 4) Accumulate receipts and when reasonable reimbursement is due, a) Obtain a claim form from your Plan Administrator. b) Follow the instructions on the claim form. To avoid delay in claims payment, please include original receipts and all other requested information with your claim. (Photocopies of receipts are acceptable only when accompanied by a claims payment statement from another carrier). the expense was incurred. However, we must receive your . of the calendar year following the year in which the expense being claimed was incurred. If not, your claim will not be paid under any circumstances. ! We must receive your receipts for 2006 before 1) We pay benefits based on dental services, financial limits and treatment frequencies in the Fee schedule. 2) We apply the reimbursement percentage shown in the Schedule of Benefits to the fees shown in the Fee schedule/Fee guide as a) for services performed in British Columbia or outside Canada, if your province of residence is British Columbia  the fees in the Fee schedule b) for services performed in Canada but outside British Columbia the fees in the Fee guide in the province/territory of service c) for services performed outside Canada if your province of residence is not British Columbiathe fees in the Fee guide in 3) Fees in excess of the amount shown in the applicable Fee schedule/Fee guide will be your responsibility. Plan A covers services for the care and maintenance of teeth, including procedures to restore teeth to natural or normal function. Eligible expenses per person include, but are not limited to, the basic services i) complete − provided we have not paid for any other exam by the same Dentist in the past 6 months –1 per 3 year ii) recall − 2 per calendar year iii) specific − provided we have not paid for any other exam iv) consultations (as a separate appointment). i) diagnostic ii) panoramic − 1 per 2 year period iii) complete mouth series − 1 per 3 year period All x-rays combined shall not exceed the dollar limit for a c) diagnostic models − 1 set per calendar year. a) scaling b) polishing − 2 per calendar year c) topical application of fluoride − 2 per calendar year d) fixed space maintainers e) preventive restorative resins and pit and fissure sealants − combined limit of 1 per tooth in a 2 year period. No age limit. a) fillings to restore tooth surfaces broken down as a result of decay – limited to a dollar amount equal to a 5 surface filling ii) composite (tooth coloured) fillings on permanent front On permanent posterior (molar) teeth and all primary teeth, we pay the bonded amalgam rate for composite fillings. b) stainless steel crowns on primary and permanent teeth − once c) inlays or onlays − only 1 inlay or onlay on the same tooth will be covered in a 5 year period. Where other material would suffice, you will be responsible for the difference between the cost of the chosen material and the cost of alternative material. 4) Endodontics – for the treatment of diseases of the pulp chamber and pulp canal including, but not limited to root canals − 1 per 5) Periodontics – for the treatment of diseases of the soft tissue (gum) and bone surrounding and supporting the teeth, excluding bone and tissue grafts, but including the following: a) occlusal adjustment and recontouring – a combined yearly b) root planing c) gingival curettage − 1 per sextant in a 5 year period d) osseous surgery – 1 per sextant in a 5 year period a) removal, repairs, and recementation of fixed appliances b) rebase and reline of removable appliances − a combined limit of 1 per upper and 1 per lower prosthesis in a 2 year period c) tissue conditioning − 2 per upper and 2 per lower prosthesis in d) gold foil – only when used to repair existing gold restorations. b) other routine oral surgical procedures c) anesthesia in conjunction with surgery shall not exceed the You are eligible for Plan B services when your Dentist recommends replacement of your missing teeth, or reconstruction of your teeth (where basic restorative methods cannot be used satisfactorily). Mounted x-rays and/or diagnostic casts may be required for our Plan B services include, but are not limited to, the following: a) inlays or onlays involved in bridgework bruxing guards − 2 appliances in a 5 year period (no benefit is payable for the replacement of lost, broken, or stolen bruxing 1) Only 1 major restorative service involving the same tooth will be 2) Crowns and fixed bridges on permanent posterior (molar) teeth are limited to the cost of the gold restoration. 3) Only 1 upper and 1 lower denture (complete or partial) is eligible 4) No benefit is payable for the replacement of lost, broken, or stolen dentures. Broken dentures may be repaired under Plan A. 5) Veneers, crowns, bridges, inlays, and onlays are subject to the conditions outlined in our Fee schedule. Where other material would suffice, you will be responsible for the difference between the cost of the chosen material and the cost of alternative material. Benefits are payable for orthodontic services performed on or after the effective date of your coverage. Plan C covers orthodontic services provided to maintain, restore, or establish a functional alignment of the 1) The lifetime benefit maximum under Plan C is shown in the 2) No benefit is payable for the replacement of appliances which are 3) Services done for the correction of temporomandibular joint (TMJ) 4) Treatment performed solely for splinting is not covered. You are entitled to the services of a Dentist if, while travelling or on vacation outside your province of residence, you require emergency dental care. You will be reimbursed according to our Fee schedule. The following are not Eligible expenses under your dental plan: 1) items not listed in our Fee schedule and fees in excess of those 2) any item not specifically included as a benefit 3) charges for broken appointments, oral hygiene or nutritional instruction, completion of forms, written reports, communication costs, or charges for translating documents into English 4) procedures performed for congenital malformations or for purely 5) charges for drugs, pantographic tracings, and grafts 6) charges for implants and/or services performed in conjunction with implants, except as indicated in our Fee schedule 7) anesthesia not done in conjunction with surgery, and charges for 8) charges for services related to the functioning or structure of the jaw, jaw muscles, or temporomandibular joint 10) recent duplication of services by the same or different Dentist 11) any extra procedure which would normally be included in the basic 12) services or items which would not normally be provided, or for which no charge would be made, in the absence of dental benefits 13) travel expenses incurred to obtain dental treatment. 1) Present your ID card to your Dentist’s office. It is important to ask if your dental benefits will cover the entire cost of your treatment. To avoid any misunderstanding, we suggest that your Dentist submit an outline of the proposed services to us ) , This is important especially when your Dentist is recommending extensive dental work. This will help you understand what portion of the Dentist’s bill must be paid by you in the event that you wish to proceed with the treatment 2) We suggest that you submit claims within / completed date of services (earlier if possible). Failure to submit a claim within the 90 day limit will not invalidate the claim if it is submitted as soon as reasonably possible. However, in no event will we pay any claim or adjustment submitted later than # 3) We require a separate claim form for each member of your family who has received dental services. Be sure to include the following b) name and birthdate of the person receiving the dental care c) your group, ID, and Dependent(s) numbers (this information is e) whether you have coverage through another plan. Claims information regarding the other carrier is not retained on our files. If you or your Dependents are covered by two plans, your Dentist must complete two separate dental claim forms (one for each plan). Incomplete claims will be returned for 4) Before your Dentist starts treatment, please ask them how billing is a) We will pay the Dentist directly for services provided under this dental plan when we receive a claim form signed by the Dentist, certifying these services were performed and the fee b) If you have paid your Dentist directly, we will reimburse you the benefit amount when we receive a claim form or receipts signed by your Dentist. We will send you a cheque when the Because we do not return original receipts, we will accept photocopies. Do not hold receipts until the completion of i) We suggest that you submit orthodontic claims within of the date the payment was due to your ii) Reimbursement is made if the complete and correct claims information is received within 1 year of the due date. However, no benefit is payable for claims not i) Have your orthodontist complete the “Certified Specialist in Orthodontics Standard Information Form” (the treatment plan) before treatment starts. The treatment plan must include a brief description of treatment to be performed, a breakdown of the fees to be charged, and the ii) If the payment schedule or treatment changes, we require iii) We will retain your treatment plan on file. If we do not have your treatment plan on file we are unable to pay: iv) Claims for consultations, exams and records (x-rays, study models, etc.) will be reimbursed without a treatment i) If you are paying in monthly or quarterly installments, submit receipts for the monthly or quarterly fees on a regular basis – as treatment progresses. Claims receipts received by us which are over 1 year old will not be ii) If you paid any amount to the Dentist before treatment is complete, we will allow an initial payment amount and then prorate the balance into monthly payments to you iii) As long as your coverage is effective, monthly or quarterly reimbursements will be made to you until the dollar maximum is reached or the treatment is complete,

Source: http://www.cope378.ca/sites/all/files/BENEFITS-BCTRANSIT.pdf