Schedule 1-2

What health benefits do I get with Health Plan 2?

The schedule below describes the extended health care and prescription drug coverage for both Plans 1 and Plan 2.

Please note the following:

There is no lifetime maximum with these plans.

Coverage maximums per year are noted below.

Coverage maximums are per benefit year (unless stated otherwise)

and apply to each plan subscriber and insured dependent.

You are not required to pay any deductible.

Qualified applicants who submit Form 2 may be considered for the Optimum level of health coverage at no additional charge.

DESCRIPTION

Coinsurance (Percentage the Insurer pays, subject to coverage maximums, applies to all categories of coverage unless otherwise specifically stated)

Annual Plan Maximum

Prescription Drugs (Pay Direct Drug Card system) Benefits include drugs legally requiring a prescription, diabetic needles and syringes. Pay generic only unless otherwise indicated in the prescription. Benefits do not include smoking cessation products and medication for the treatment of obesity, erectile dysfunction and infertility.

Out of Country Travel Emergency medical services (60 day/trip,

per CALENDAR year)

Hospital Accommodations Semi private room in a public general hospital

Private Duty Nursing Services of an R.N or R.P.N or L.P.N

Paramedical Services

Group 1: Physiotherapist, Psychologist, Speech Therapist

Group 2: Podiatrist, Chiropodist

Group 3: Registered Massage Therapist (referral req.), Chiropractor, Osteopath, Naturopath, Acupuncturist, Dietician, Occupational Therapist

Vision (maximums apply every 24 months based on date of first paid claim) Prescription eye glasses and/or contact lenses and/or laser eye surgery Eye exams (applies only to adults ages 20 years 64 years inclusive)

Audio Hearing aids, repairs or replacement parts (maximums apply every 5 years based on date of first paid claim)

Accidental Death accidental injury to natural teeth, submit accident report immediately

Medical Items includes items such as wheelchair, hospital bed,

glucometer and lancets, orthotics, prosthetics, ventilator, pressure gradient stockings etc. Each individual item is scaled to usual and customary limits.

Emergency Transportation Land or air ambulance

Medical Alert Bracelets Maximums apply every 2 years based on date of first paid claim

Employee Assistance Program

Additional health care and hospital coverage may be added to all plans. Click Here for Details

70%

100%

$300 per discipline

$400 per discipline

$500 per discipline

$300 combined

$400 combined

$500 combined

$300 combined

$400 combined

$500 combined

$300

$400

$600

$1,500

$2,500

100%

Co-ins
$100
$65

100%

Co-ins
$150
$65

$250
Included

in total

$1,250

$1,500

$5,000

Unlimited

100% Co-ins

Unlimited

$50

Included

$5,000

N/A

$750

$1,000

$10,000

90% Co-ins

$1,000,000 100% Co-ins

N/A

$3,000 100% Co-ins

$5,000

$2,500

$5,000

ESSENTIAL

COMPLETE

OPTIMUM

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