CUPE Local 3902 (Unit 5): Schedule of Benefits

Health Benefit Plan

This schedule describes the deductibles, co-pays and maximums that may be applicable if you are included in this Employee Group.Complete benefit details are provided in the Description of  Benefits section of this website. Be sure to read these pages carefully. They show the conditions, limitations and exclusions that may apply to the benefits. All dollar maximums are based on paid Canadian dollars. You are covered for only those specific benefits for which you are enrolled.This group benefit plan is intended to supplement your provincial health insurance plan. The benefits shown below will be eligible, if they are medically necessary for the treatment of an illness or injury, and reimbursement will be limited to reasonable and customary charges, in addition to Specific limitations stated in the Schedule of Benefits below.

Deductible: Nil
Overall Maximums:

Hospital Accomodation:

Medical Items and services, Emergency Transportation and Paramedical Services

 

$1,000 per covered person per calendar year.

$2,000 per calendar year combined

All Other Health Benefits Reasonable and customary charges

 

Your Plan Covers: Your Co-Pay Maximum Plan Pays:
Prescription Drugs – Pay Direct Drug Card 10% of allowed amount per prescription or refill $6,000 per covered person per calendar year
Hospital Accomodation

  • Public general hospital – semi-private room
 

0%

 

Reasonable and customary charges, included in the Overall Maximum as stated above

Medical Items and Services
  • Footwear
    • Custom-made boots or shoes, custom-made foot orthotics, adjustment to orthopedic shoes, adjustment to custom made foot orthotics and footwear as an integral part of a brace
  • Cataract Eye wear
  • Optometric eye examinations
  • All other Medical Items and Services – see the description of benefits section for details
  • Emergency Transportation
  • Accidental Dental
20%  

$150 per calendar year combined, included in the Overall Maximum as stated aboveOnce per lifetime, included in the overall Maximum as stated above

Once every 24 months, included in the Overall Maximum as stated aboveReasonable and customary charges, included in the Overall Maximum as stated aboveReasonable and customary charges, included in the Overall Maximum as stated above.

Reasonable and customary charges, included in the Overall Maximum as stated above

Paramedical Services

  • Chiropractor
  • Registered Massage Therapist*
  • Naturopath
  • Osteopath
  • Physiotherapist
  • Speech Therapist
  • Chiropodist/Podiatrist
  • Psychologist (including Master of Social work and Psychotherapist)

*(Physician M.D or nurse practitioner recommendation required)

$500 per Calendar year for all practitioners combined, included in the Overall Maximum as stated above

 

 

$900 per calendar year, included in the Overall Maximum as stated above

Vision
Prescription eye glasses or contact lenses, or medically necessary contact lenses 0% $200 per 24 consecutive months

 For a full description of the Health Benefit, refer to the Description of Health Benefits.

Travel Benefit Plan

This schedule describes the deductibles, co-pays and maximums that may be applicable if you are included in this Employee Group.

Complete benefit details are provided in the Description of Travel Benefits section of this website. Be sure to read these pages carefully. They show the conditions, limitations and exclusions that may apply to the benefits. All dollar maximums are based on paid Canadian dollars. You are covered for only those specific benefits for which you are enrolled.

This group benefit plan is intended to supplement your provincial health insurance plan. Hospital and medical services are eligible only if your provincial health insurance plan provides payment toward the cost of incurred services. The benefits shown below will be eligible, if they are medically necessary for the treatment of an illness or injury, and reimbursement will be limited to reasonable and customary charges, in addition to specific limitations stated in the Schedule of Benefits below.

Reimbursement of eligible benefits for emergency services will be made only if the services were required as a result of emergency illness or injury that occurred while you were vacationing or traveling for other than health reasons.

The patient must contact Green Shield Canada Travel Assistance within 48 hours of commencement of treatment. Failure to notify us within 48 hours may result in benefits being limited to only those expenses incurred within the first 48 hours of any and each treatment/incident or the plan maximum, whichever is the lesser of the two.

Deductible: Does not apply
Overall Maximum: Does not apply
Your Co-Pay: Does not apply

 

Your Plan Covers: Maximum Plan Pays:
Maximum Number of Days per Trip Equal to the number of days under Provincial plan or as long as comparable OHIP covered is in effect
Emergency Services $1,000,000 per covered person per calendar year
Referral Services $50,000 per covered person per calendar year

For a full description of the Travel Benefit, refer to the Description of Travel Benefits.

Dental Benefit Plan

This schedule describes the deductibles, co-pays and maximums that may be applicable if you are included in this Employee Group.

Complete benefit details are provided in the Description of Dental Benefits section of this website. Be sure to read these pages carefully. They show the conditions, limitations and exclusions that may apply to the benefits. All dollar maximums are expressed in Canadian dollars. You are covered for only those specific benefits for which you are enrolled.

Deductible: Nil
Fee Guide: The current minus one year,  Ontario Dental Association Fee Guide for General Practitioners.

For independent Dental Hygienists, the lesser of, the current minus one year Ontario Dental Hygienists’ Association Fee Guide or Ontario Dental Association Fee Guide for General Practitioners

 

Your Plan Covers: Your Co-Pay Maximum Plan Pays:
Basic and Comprehensive Basic Services 20% $1,250 per covered person per benefit year

For a full description of the Dental Benefit, refer to the Description of Dental Benefits.