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Group Benefits

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Employer /
Group Name*:		 Gender: Male  Female Email*:
Phone*: Postal Code*: Province:
Plan:
Extended Health Care		 Silver Gold Platinum Diamond Best Time to call: Type*: Single      Family
 
 
Optional:
Dental Care
Silver: Covers preventive care and routine basic procedures like fillings, x-rays and denture repair
Gold: Includes preventive and Basic services and major procedures including crowns, dentures and veneers
Platinum: Coverage for preventive and basic services, major procedures and orthodontic services.
 
Premium Contributions: Extended Health Care (Employer %)            (Employee %)
  Dental Care                   (Employer %)            (Employee %)
 

Silver

(3+ employees)

Gold

(3+ employees)

Platinum

(6+ employees)

Diamond

(10+ employees)
Eye Exams, Glasses, Contact Lenses & Surgery - $60 per 2 years (eye exams only) Eye Exams, Glasses, Contact Lenses & Surgery - $150 per 2 years Eye Exams, Glasses, Contact Lenses & Surgery - $300 per 2 years Eye Exams, Glasses, Contact Lenses & Surgery - $300 per 2 years
Diabetic Supplies & Equipment - $300 Diabetic Supplies & Equipment - $300 Diabetic Supplies & Equipment - $500 Diabetic Supplies & Equipment - $500
Oxygen Equipment - $500 Oxygen Equipment - $500 Oxygen Equipment - $500 Oxygen Equipment - $500
Custom Made Foot Orthotics - 1 pair per 5 years(adult) 1pair per year (children under 16 yrs.) Custom Made Foot Orthotics - 1 pair per 5 years(adult) 1pair per year (children under 16 yrs.) Custom Made Foot Orthotics - 1 pair per 5 years(adult) 1pair per year (children under 16 yrs.) Custom Made Foot Orthotics - 1 pair per 5 years(adult) 1pair per year (children under 16 yrs.)
Ostomy Supplies - $300 Ostomy Supplies - $300 Ostomy Supplies - $300 Ostomy Supplies - $300
Ambulance - $1,500 Ambulance - Unlimited Ambulance - Unlimited Ambulance - Unlimited
Air Ambulance - Unlimited Air Ambulance - Unlimited Air Ambulance - Unlimited Air Ambulance - Unlimited
Casts and Crutches - Unlimited Casts and Crutches - Unlimited Casts and Crutches - Unlimited Casts and Crutches - Unlimited
Preferred Hospital Rooms - Unlimited
 Preferred Hospital Rooms - Unlimited Preferred Hospital Rooms - Unlimited Preferred Hospital Rooms - Unlimited
Private Duty Nursing - $2,500 Private Duty Nursing - $2,500 Private Duty Nursing - $5,000 Private Duty Nursing - $10,000
Accidental Injury to Natural Teeth - $2,000 per injury Accidental Injury to Natural Teeth - $2,000 per injury Accidental Injury to Natural Teeth - $2,000 per injury Accidental Injury to Natural Teeth - $5,000 per injury
Wheelchairs, Motorized Scooters & Adjustable Beds - $500 per policy per 5 years Wheelchairs, Motorized Scooters & Adjustable Beds - $500 per policy per 5 years Wheelchairs, Motorized Scooters & Adjustable Beds - $500 per policy per 5 years Wheelchairs, Motorized Scooters & Adjustable Beds - $500 per policy per 5 years
Artificial Limbs, Eyes & Larynx - $10,000 lifetime Artificial Limbs, Eyes & Larynx - $10,000 lifetime Artificial Limbs, Eyes & Larynx - $10,000 lifetime Artificial Limbs, Eyes & Larynx - $10,000 lifetime
Patient Walkers - $200 per policy per 3 years Patient Walkers - $200 per policy per 3 years Patient Walkers - $200 per policy per 3 years Patient Walkers - $200 per policy per 3 years
Breast Prosthesis -1 if lateral / 2 if bilateral per 2 years Breast Prosthesis -1 if lateral / 2 if bilateral per 2 years Breast Prosthesis -1 if lateral / 2 if bilateral per 2 years Breast Prosthesis -1 if lateral / 2 if bilateral per 2 years
Health Supplies & Equipment - $500 combined Health Supplies & Equipment - $500 combined Health Supplies & Equipment - $500 combined Health Supplies & Equipment - $500 combined
Prescription Drugs- (coverage per person per policy year) -
70% of cost upto $500 Formulary Drugs only Vaccines / Immunizations.		 Prescription Drugs- (coverage per person per policy year) -
80% of cost upto $1,500 Formulary and Non- Formulary Drugs Vaccines / Immunizations.		 Prescription Drugs- (coverage per person per policy year) -
100% of cost upto $5,000 Formulary and Non- Formulary Drugs Vaccines / Immunizations.		 Prescription Drugs- (coverage per person per policy year) -
100% Unlimited Formulary and Non- Formulary Drugs Vaccines / Immunizations.
  Travel (30 days) - $5 million total coverage Travel (30 days) - $5 million total coverage Travel (30 days) - $5 million total coverage
  Out- of-Province Referral (within Canada) - $50,000 lifetime Out- of-Province Referral (within Canada) - $50,000 lifetime Out- of-Province Referral (within Canada) - $50,000 lifetime
  Therapeutic Shoes - $200 Therapeutic Shoes - $200 Therapeutic Shoes - $200
  Hearing Aids - $500 per 5 years Hearing Aids - $500 per 3 years Hearing Aids - $500 per 3 years
  Health Practitioners - $300 combined Health Practitioners - $300 per specialist per year Health Practitioners - $500 per specialist per year
    Blood Pressure Monitor - 1 per policy per 5 years Blood Pressure Monitor - 1 per policy per 5 years
    Medical Second Opinion - Immediate Family Medical Second Opinion - Immediate & Extended Family (including in-laws).

Dental Benefits

Silver

(3+ employees)

Gold

(3+ employees)

Platinum

(3+ employees)
Preventive Services - 80% Preventive Services - 100% Preventive Services - 100%
Basic Services - 80% Basic Services - 100% Basic Services - 100%
  Major Services - 50% Major Services - 80%
    Orthodontic Services (for dependants under 18 years of age) - 50% ($1,500 lifetime maximum)
 
Preventive Services:
  • cleaning, scaling and polishing(6 month recall)
  • topical fluoride treatment
  • pit and fissure sealants
  • occlusal adjustment and equilibration
  • interproximal disking of teeth
  • bruxism appliances
 Basic Services:
  • examinations and dental x-rays
  • routine extractions and fillings
  • basic oral surgery performed by dentist, including anaesthesia
  • root canal therapy
  • denture repairs, relining and rebasing
  • surgical and non-surgical periodontal treatment
 Major Services:
  • full or partial upper and lower dentures
  • inlays, onlays, crowns, and veneers
  • denture adjustments
  • occlusal adjustment and equilibration
  • interproximal disking of teeth
  • bruxism appliances
 Orthodontic Services:
(for dependants under 18 years of age)
  • diagnosis and treatment for the correction of malocclusion or malposed teeth
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