Prism Precision
P1
P2
P3
Please see “Benefit Descriptions”
for more details
PRESCRIPTION DRUGS - maximum
$250 per year
Paid at 70%
Brand name drugs covered if no generic
equivalent is available
per person
Not covered
DENTAL - Combined maximums
Not covered
per person for Schedules A, B & C
(if applicable)
Not covered
$250 per year
$500 in the first 12 months
$750 in the next 12 months
$1,000 every 12 months thereafter
Schedule A – Basic
Not covered
Paid at 70%
Paid at 80%
Not covered
Not covered
Paid at 60% in first 12 months
Paid at 70% in the next 12 months
Paid at 80% thereafter
Not covered
Not covered
Schedule B – Basic Comprehensive
Schedule C – Major Services
Paid at 50%, starting in the
3rd benefit year
EXTENDED HEALTH
Vision - maximum per person
$150 every 24 months
Not covered
$150 every 24 months
Accidental Dental - maximum per person
$5,000 per year
$2,500 per year
$5,000 per year
Ambulance Transportation
Includes land and air
Includes land and air
Includes land and air
Hearing Aids - maximum per person
$300 in the first 4 years
$500 every 4 years thereafter
$300 every 4 years
$300 in the first 4 years
$500 every 4 years thereafter
Home Support Services - maximum
per person
$1,500 in the first 12 months
$2,500 in the next 12 months
$5,000 every 12 months thereafter
$1,500 per year
$1,500 in the first 12 months
$2,500 in the next 12 months
$5,000 every 12 months thereafter
Medical Items - maximum per person
$1,500 in the first 12 months
$2,500 in the next 12 months
$5,000 every 12 months thereafter
foot orthotics - $250 every 24 months
stockings - 2 pairs every 4 months
surgical brassieres - 2 every 12 months
$1,500 per year
foot orthotics - $250 every 24 months
stockings - 2 pairs every 4 months
surgical brassieres - 2 every 12 months
$1,500 in the first 12 months
$2,500 in the next 12 months
$5,000 every 12 months thereafter
foot orthotics - $250 every 24 months
stockings - 2 pairs every 4 months
surgical brassieres - 2 every 12 months
Covered
$50 every 24 months
Covered
Not covered
Covered
$50 every 24 months
Medical Services
Eye examinations - maximum per person
Professional/Registered Therapists
- maximums per practitioner per person
• Chiropractor, Footcare Specialist
(Chiropodist/Podiatrist), Naturopath,
Osteopath, Physiotherapist,
Massage Therapist, Acupuncturist
• Psychologist, Speech Therapist
TRAVEL - maximum per person
[available up to age 65]
SEMI-PRIVATE HOSPITAL ACCOMMODATION
Optional benefit - medical
questionnaire required
- maximum per person
PRESCRIPTIO
Prescription drugs/m
prescription by law.
NOTE: Excludes vit
cessation pr
DENTAL
Schedule A – Bas
• Preventative clea
• Routine examinat
• Fluoride treatmen
• Fillings and extra
• Pit and fissure se
• Space maintainer
Schedule B – Bas
• Periodontal treatm
treatment of gum
• Endodontics – ro
• Denture cleaning
Schedule C – Ma
• Dentures
• Standard crown r
• Standard bridges
• Standard repair o
NOTE: All of the de
Association
$20 per visit; 20 visits per year
$400 per year
$20 per visit; 15 visits per year
$300 per year
$20 per visit; 20 visits per year
$400 per year
$1,000,000 per year
10 days per trip
$1,000,000 per year
10 days per trip
$1,000,000 per year
10 days per trip
NOTE: Optional Benefit – Additional premium required, please refer to pages (6) and (7)
$200 per day, 30 days per year
$200 per day, 30 days per year
$200 per day, 30 days per year
Prism
This brochure ou
terms, conditions
Green Shield Ca
Benefit
Descriptions
Benefit
Descriptions
Benefit
Benefit
Benefit
Descriptions
Descriptions
Descriptions
PRESCRIPTION DRUGS
EXTENDED HEALTH
RESCRIPTION
TION DRUGS
PRESCRIPTION
DRUGS
DRUGS
Prescription
drugs/medications
that have been approved for use in Canada that requireEXTENDED
a
EXTENDED
HEALTH HEALTH
EXTENDED HEALTH
Vision
Medical Services
Includes diagnostic tests and x-rays, dialysis equipment, laboratory tests, radioactive
prescription by law.
Prescription eye glasses, contact lenses, laser eye surgery or replacement parts to
Medical Services
Medical Services and
Medical
Services
escription
ugs/medications
drugs/medications
that
Prescription
have been
that
drugs/medications
approved
have beenforapproved
usethat
in Canada
have
for use
been
that
inapproved
Canada
require that
afor use
require
in Canada
a
that requireVision
a
eye examinations.
Vision
Vision
prescription eye glasses.
Includes diagnostic
Includestests
diagnostic
and x-rays,
Includes
tests dialysis
anddiagnostic
x-rays,
equipment,
dialysis
tests equipment,
laboratory
and x-rays,tests,
dialysis
laboratory
radioactive
equipment,
tests, treatments
radioactive
laboratory
treatments
tests, radioactive
escription
law.
by law.NOTE:
prescription
by law.
Excludes
vitamins, patent or proprietary medicines, over-the-counter drugs, smoking
Prescription Prescription
eye glasses, eye
contact
glasses,
Prescription
lenses,
contact
lasereye
lenses,
eyeglasses,
surgery
lasercontact
eye
or replacement
surgery
lenses,
orlaser
replacement
partseyetosurgery
partsortoreplacement parts to
and eye examinations.
and eye examinations.
and eyeEye
examinations.
NOTE:
examinations are available only in those provinces where eye examinati
cessation products, erectile dysfunction (ED) agents, fertility and obesity drugs. prescription prescription
eye glasses. eye glasses.
prescription
eye glasses.regarding eye examinations please see description under
NOTE:
For information
OTE:
es vitamins,
Excludes
patent
vitamins,
NOTE:
or proprietary
patent
Excludes
or medicines,
vitamins,
proprietarypatent
over-the-counter
medicines,
or proprietary
over-the-counter
drugs,
medicines,
smoking
drugs,
over-the-counter
smoking drugs, smoking
covered by the provincial government health plan on an annual basis.
Medical Services.
NOTE: Eye examinations
NOTE: Eye examinations
are available
NOTE:are
Eye
only
available
examinations
in thoseonly
provinces
inare
those
available
where
provinces
eye
onlyexaminations
where
in those
eyeprovinces
examinations
are notwhereare
eyenot
examinati
on products,
cessationerectile
products,
dysfunction
cessation
erectile dysfunction
(ED)
products,
agents,erectile
(ED)
fertility
agents,
dysfunction
and fertility
obesity(ED)
and
drugs.
agents,
obesity fertility
drugs. and obesity drugs. NOTE: For information
DENTAL
NOTE: For information
regarding
NOTE:
eye
regarding
examinations
For information
eye examinations
please
regarding
see description
please
eye examinations
see under
description
please
under
see description under
covered by the
covered
provincial
by the
government
provincial
covered
government
health
by theplan
provincial
health
on an annual
government
plan onbasis.
an annual
health basis.
plan on an annual basis.
Professional/Registered
Therapists
Medical Services.
Medical Services.
Medical
Services.
Accidental
Dental
ENTAL
DENTALA – Basic
Chiropractor, Footcare Specialists (Chiropodist/Podiatrist), Naturopath, Osteopath,
Schedule
The repair or replacement of natural teeth which were damaged as a result of an accident to the
Professional/Registered
Professional/Registered
Therapists
Professional/Registered
Therapists
Therapists
Physiotherapist,
Psychologist,
Speech Therapist, Acupuncturist and Registered
• Preventative cleaning and polishing (every 9 months)
Accidental Accidental
Dental
DentalAccidental
mouth (blowDental
to the mouth).
Chiropractor,
Footcare Specialists
Footcare
Chiropractor,
(Chiropodist/Podiatrist),
Specialists
Footcare
(Chiropodist/Podiatrist),
Specialists
Naturopath,
(Chiropodist/Podiatrist),
Naturopath,
Osteopath, Osteopath,
Naturopath, Osteopath,
hedule
Basic A – Basic
Schedule
A – Basic x-rays
Massage
Therapist
(RMT).
• Routine examinations,
The repair orThe
replacement
repair or replacement
of natural
The repair
teeth
of natural
or
which
replacement
teeth
were which
damaged
of natural
wereasdamaged
ateeth
resultwhich
ofasan
awere
result
accident
damaged
of an
to the
accident
as a result
to theof an accident
to the Chiropractor,
Physiotherapist,
Physiotherapist,
Psychologist,Psychologist,
Speech
Physiotherapist,
Therapist,
SpeechAcupuncturist
Psychologist,
Therapist, Acupuncturist
Speech
and Registered
Therapist,
and Registered
Acupuncturist and Registered
Preventative
cleaning andcleaning
polishing
Preventative
and
(every
polishing
9 cleaning
months)
(every
9children
months)
polishing (every 9 months)
• Fluoride
treatments
forand
mouth (blowmouth
to the(blow
mouth).
to theNOTE:
mouth
mouth).(blow
to the
mouth).
Damage
to teeth
as a result of eating something is not covered.
Massage Therapist
Massage
(RMT).
Therapist (RMT).
MassageAllTherapist
(RMT). Health benefits are not payable for services and supplie
minations,
Routine examinations,
x-rays • Fillings
Routine
x-rays
examinations,
NOTE:
of the Extended
and
extractionsx-rays
Fluoride
tments for
treatments
children
• Fluoride
forand
children
treatments
for children
a chronic care or psychiatric hospital or institution, chronic care unit of a ge
Pit
fissure
sealants
NOTE: Damage
NOTE:
NOTE:
to teeth
Damage
as atoresult
teeth
ofaseating
Damage
a result
something
to
of teeth
eatingas
issomething
not
a result
covered.
ofiseating
not covered.
something is not covered.
Ambulance
Transportation
NOTE:
NOTE:
the Extended
All of theHealth
Extended
benefits
All
Health
ofare
the
benefits
not
payable
areisHealth
not
for
payable
services
benefits
for
are
services
supplies
nothome
payable
and
provided
supplies
for in
services
provided
insupplie
Fillings
extractions
and extractions
• Fillings
and extractions
or
when
aExtended
patient
confined
to and
a nursing
or home
for theand
aged
and
Space maintainers
and general anaesthetics
When required as the result of an accident or acute physical disability, professional land
or airAll ofNOTE:
a chronic care
a chronic
or psychiatric
care orhospital
psychiatric
a chronic
or institution,
hospital
care
or psychiatric
or chronic
institution,
care
hospital
chronic
unit or
of care
institution,
a general
unit ofhospital,
chronic
a general
care
hospital,
unit of a ge
Pit
re sealants
and fissure sealants
• Pit and fissure sealants
provincial
government
assistance.
AmbulanceAmbulance
Transportation
Transportation
Ambulance
ambulance toTransportation
the nearest hospital equipped to provide the required treatment.
or when
is aconfined
patient to
isorconfined
awhen
nursing
a to
patient
home
a nursing
oris home
confined
home
foror
to
thehome
a aged
nursing
for
and
the
home
receives
aged
or and
homereceives
for the aged and
Space
ainers maintainers
and general
• and
Space
anaesthetics
general
maintainers
general anaesthetics
Schedule
B –anaesthetics
Basicand
Comprehensive
When required
When
as the
required
resultasofthe
an
When
result
accident
required
of an
or acute
accident
as thephysical
result
or acute
ofdisability,
anphysical
accident
professional
disability,
or acuteprofessional
land
physical
or air
disability,
land orprofessional
air
land or airor when a patient
provincial government
provincial government
assistance.
provincial
assistance.
government assistance.
TRAVEL
• Periodontal treatment including: cleaning and scaling (8 units every 12 months) – ambulance to
ambulance
the nearest
to the
hospital
nearest
ambulance
equipped
hospital
totothe
equipped
provide
nearestthe
tohospital
provide
required
equipped
the
treatment.
required
to provide
treatment.
the required treatment.
Hearing
Aids
hedule
Basic Comprehensive
B – Basic
Schedule
Comprehensive
B of
– Basic
Comprehensive
treatment
gums and
tissues of the mouth
Standard hearing aids, repairs or replacement parts.
TRAVEL TRAVEL
TRAVEL
Periodontal
reatment including:
treatment
• Periodontal
cleaning
including:
and
treatment
scaling
and
including:
(8 units
scaling
every
cleaning
(8 12
units
months)
and
every
scaling
12
– months)
(8 units–every 12 months) – Hearing Aids
Services that are required as a result of emergency illness or injuries which occurred
Endodontics
–cleaning
root canal
therapy
Hearing Aids
Hearing Aids
reatment
gums andoftissues
gums• of
and
treatment
the
tissues
mouth
ofofgums
the repairs,
mouth
and tissues
of the
you were vacationing or traveling for other than health reasons. Covers hospital ser
Denture
cleaning,
rebasing
andmouth
relining
Standard hearing
Standard
aids,hearing
repairsaids,
orStandard
replacement
repairs
hearing
or not
replacement
parts.
aids, repairs
parts.
or replacement
NOTE:
Does
include
the
replacement
cost parts.
for batteries.
Services thatServices
are required
that are
as arequired
result
Services
ofasemergency
that
a result
are required
of illness
emergency
as
or ainjuries
result
illnessof
which
oremergency
injuries
occurred
which
illness
while
occurred
or
injuries
while
whichrepatriati
occurred
Endodontics
– root canal–therapy
root
• Endodontics
canal therapy– root canal therapy
and
accommodation,
medical/surgical
services,
emergency
transportation,
you were vacationing
you were vacationing
or traveling
youor
for
were
traveling
other
vacationing
than
forhealth
otherorthan
reasons.
traveling
health
Covers
forreasons.
other
hospital
than
Covers
health
services
hospital
reasons.
services
Covers hospital ser
Denture
ning, repairs,
cleaning,
rebasing
•repairs,
Denture
andrebasing
relining
cleaning,
andrepairs,
relining
rebasing and relining
air
ambulance.
Schedule
C
– Major
Services
NOTE: DoesNOTE:
not include
Does the
not replacement
include
NOTE:the
Does
replacement
costnotforServices
include
batteries.
costtheforreplacement
batteries. cost for batteries.
Home
Support
and accommodation,
medical/surgical
and
medical/surgical
accommodation,
services, emergency
services,
medical/surgical
transportation,
emergencyservices,
transportation,
repatriation
emergency
repatriation
andtransportation,
and repatriati
• Dentures
Services of a Registered Nurse (RN), Registered Practical Nurse (RPN), or Licensed Practical
Nurse and accommodation,
air ambulance.
air ambulance.
air ambulance.
hedule
Major CServices
– Major
Schedule
ServicesCcrown
– Major
Servicesor onlays on natural teeth
NOTE:
Travel Benefits are not available after the age of 65.
• Standard
restorations
Home Support
Home
Services
Support Services
Home
Services
(LPN) inSupport
the home
when certified medically necessary by the attending physician.
Dentures
• Dentures
Standard bridges, including pontics, abutment retainers/crowns on natural teeth
Services of aServices
Registered
of aNurse
Registered
(RN),
Services
Nurse
Registered
of a(RN),
Registered
Practical
Registered
Nurse
Nurse
Practical
(RN),
(RPN),
Registered
Nurse
or Licensed
(RPN),
Practical
or
Practical
Licensed
Nurse
Nurse
Practical
(RPN), orNurse
Licensed Practical Nurse
NOTE: Travel
NOTE:
NOTE:
Benefits
Travel
areBenefits
not available
are not
Travel
after
available
Benefits
the ageafter
of
are65.
the
notage
available
of 65.
after the age of 65.
Standard
wn restorations
crown restorations
or
• Standard
onlays onor
crown
natural
onlays
restorations
teeth
on naturalorteeth
onlays
on natural
SEMI-PRIVATE
HOSPITAL
ACCOMMODATION
repair
or
recementing
of crowns,
onlays teeth
and bridgework on natural teeth (LPN) in the(LPN)
homeinwhen
the home
certified
when
(LPN)
medically
certified
in the
necessary
home
medically
when
bynecessary
certified
the attending
medically
by thephysician.
attending
necessary
physician.
by the attending physician.
Medical
Items
Standard
dges, including
bridges,
pontics,
•including
Standard
abutment
pontics,
bridges,
retainers/crowns
abutment
includingretainers/crowns
pontics,
on natural
abutment
teeth
onretainers/crowns
natural teeth on natural teeth
• Aids for daily living include: hospital style beds including rails and mattress, decubitus
SEMI-PRIVATE
SEMI-PRIVATE
HOSPITAL
SEMI-PRIVATE
ACCOMMODATION
ACCOMMODATION
HOSPITAL
Standard
air or recementing
repair or• recementing
Standard
of crowns,repair
onlays
of crowns,
or and
recementing
bridgework
onlays and
of crowns,
bridgework
on natural
onlays
teeth
on and
natural
bridgework
teeth on natural teeth Medical Items
ThisHOSPITAL
benefit
pays for
the
difference in ACCOMMODATION
cost between standard ward and semi-private
Medical Items Medical
Items
(ulcer care)
supplies, trapeze
accommodation in a public or general (acute care) hospital when you have occupie
NOTE: All of the dental benefits are based on the current Provincial Dental
• Aids for daily
• Aids
living
for include:
daily living
hospital
Aids
include:
for
style
daily
hospital
beds
living
including
style
include:
beds
rails
including
hospital
and
mattress,
style
rails
beds
and
decubitus
mattress,
includinglancets),
decubitus
rails and
mattress,
decubitus
• Braces,
casts,
diabetic
supplies
(blood
glucose
monitor,
catheter
supplies,
This benefit This
paysbenefit
for thepays
difference
foractive
This
theinbenefit
difference
cost
between
paysinbed.
for
cost
standard
the
between
difference
ward
standard
in
and
cost
semi-private
ward
between
and
standard
semi-private
semi-private
treatment
Your
provincial
government
health
plan ward
must and
accept
or agree
Association fee guide for general practitioners.
(ulcer care) supplies,
(ulcer care)
trapeze
supplies,ostomy
(ulcer
trapeze
care)
supplies,
trapeze
supplies,
custom
made foot orthotics
accommodation
in a public orin general
apay
accommodation
public
or general
care)
inward
(acute
ahospital
public
care)
or
when
general
hospital
you (acute
have
when
occupied
care)
you have
hospital
anoccupied
when an
you have occupie
OTE:
he dental
All ofbenefits
the dental
NOTE:
are benefits
based
All ofonare
thethebased
dental
current
on
benefits
Provincial
the current
are based
Dental
Provincial
on theDental
current Provincial Dental
the(acute
standard
rate.
• Braces, casts,
• Braces,
diabetic
casts,
supplies
diabetic
• (blood
Braces,
supplies
glucose
casts,
(blood
diabetic
monitor,
glucose
supplies
lancets),
monitor,
(blood
catheter
lancets),
glucose
supplies,
catheter
monitor,supplies,
lancets),equipment
catheter supplies, accommodation
Mobility
Aids
include:
cane,
crutch,
walker,
wheelchair,
traction
active treatment
activebed.
treatment
Your provincial
bed.
active
Yourgovernment
treatment
provincialbed.
government
health
Yourplan
provincial
health
must accept
government
plan must
or agree
accept
health
to orplan
agree
must
to accept or agree
ation Association
fee guide forfee
general
guide
Association
practitioners.
for general
feepractitioners.
guide for general practitioners.
ostomy supplies,
ostomy
custom
supplies,
made
custom
ostomy
orthotics
made
supplies,
foot orthotics
custom
made
footeyes,
orthotics
• foot
Prosthetics
include:
artificial
limbs,
prosthetic accessories, modifications and repairs,
pay the standard
pay the
ward
standard
rate. ward
pay rate.
the •standard
ward rate.benefit cannot be purchased on its own.
NOTE:
The semi-private
•
Mobility
Aids
•
Mobility
include:
Aids
cane,
include:
crutch,
•
Mobility
cane,
walker,
crutch,
Aids
wheelchair,
include:
walker,
cane,
traction
wheelchair,
crutch,
equipment
traction
walker,
wheelchair,
equipment
traction
equipment
surgical
brassieres
after
a
mastectomy
Prism
• This benefit does not apply to accommodation in a long-term care facility
• Prosthetics• include:
Prosthetics
artificial
include:
limbs,
Prosthetics
artificial
eyes, limbs,
prosthetic
include:
eyes,accessories,
artificial
prosthetic
limbs,
accessories,
modifications
eyes, prosthetic
modifications
and repairs,
accessories,
repairs,
modifications
and repairs,
• Respiratory
Cardiology
includes:
continuous
positive
airwayand
pressure
pump (CPAP),
apnea
This brochure outlines benefits available. This is not a contract. Actual details,
NOTE: • The
NOTE:
• The semi-private
NOTE:
• (i.e.
semi-private
benefit
cannot
benefit
The
be purchased
semi-private
cannot care
beon
purchased
benefit
its own.
cannot
on itsbe
own.
purchased
on its
chronic
facility/hospital),
private
hospital
or own.
program treatment f
surgical brassieres
surgicalafter
brassieres
a mastectomy
after
surgical
a mastectomy
brassieres
afterdisrhythmias
a mastectomy
monitor
for respiratory
(for infants), compressor, inhalant devices, tracheotomy
Prism
Prism
terms, conditions, limitations and exclusions are detailed in the policy issued by
• This
doesbenefit
not apply
doesto•not
accommodation
This
apply
benefit
to
does
not
a long-term
apply
tohospitalization
aaccommodation
care
long-term
facility care
facility
long-term or
care
facility
Benefits
areaccommodation
notinpayable
forin
duein
toapregnancy
pregnanc
• Respiratory• Cardiology
Respiratory includes:
Cardiology
• supplies,
Respiratory
continuous
includes:
Cardiology
positive
continuous
airway
includes:
positive
pressure
continuous
airway
pump
pressure
(CPAP),
positive
pump
apnea
airway
(CPAP),
pressure
apneapump (CPAP), apnea • This benefit
oxygen
re
This
outlines
brochure
benefits
outlines
available.
This
benefits
brochure
This
available.
outlines
is not aThis
contract.
benefits
isapplication
notavailable.
Actual
a contract.
details,
This
Actual
is notdetails,
a contract. Actual details,
Green
Shield
Canada
upon
approval.
carechronic
facility/hospital),
care facility/hospital),
(i.e.private
chronichospital
care
private
facility/hospital),
or program
hospitalduring
or
treatment
program
private
facility.
hospital
treatment
or month
program
facility.period
treatment
conditions
which
commence
the first
ten (10)
followf
monitor for monitor
respiratory
fordisrhythmias
respiratory
disrhythmias
(forfor
infants),
respiratory
(for
compressor,
infants),
disrhythmias
compressor,
inhalant
(fordevices,
infants),
inhalant
tracheotomy
compressor,
devices,
tracheotomy
inhalant
devices,
tracheotomy
• monitor
Vascular
compression
includes:
intermittent
compression
pump
and sleeve,
pressure
gradient (i.e. chronic (i.e.
itions,
terms, limitations
conditions,and
limitations
terms,
exclusions
conditions,
andare
exclusions
detailed
limitations
are
in the
detailed
andpolicy
exclusions
inissued
the policy
are
by detailed
issued in
bythe policy issued by
• Benefits are
• Benefits
not payable
are not
for payable
hospitalization
• effective
Benefits
for are
hospitalization
not
to
due
for hospitalization
toorpregnancy
pregnancyordue
related
pregnancy
to pregnancy
relatedor pregnanc
datedue
of payable
thepregnancy
coverage.
supplies, oxygen
supplies, oxygen surgical
supplies,stockings
oxygen
dGreen
Canada
Shield
upon
Canada
application
Green
uponShield
approval.
application
Canadaapproval.
upon application approval.
conditions
commence
which during
commence
conditions
the first
during
which
ten the
(10)
commence
first
month
ten (10)
during
period
month
following
the first
period
ten
thefollowing
(10) month
theperiod follow
• Vascular compression
• Vascular compression
includes:
• Vascular
intermittent
includes:
compression
intermittent
compression
includes:
compression
pump intermittent
and sleeve,
pump pressure
compression
and sleeve,
gradient
pressure
pump and
gradient
sleeve, pressure gradient conditions which
effective date
effective
of the coverage.
date of theeffective
coverage.
date of the coverage.
surgical stockings
surgical stockings surgical stockings
3
3
3
3
4
4
4
4
5
5
5
5
Prism Precision® - Monthly Rates Effective January 1, 2008
Pri
Rates and/or benefits are subject to change with thirty (30) days notice to the applicant/policy holder.
NOTE: Prism Precision Monthly Rates do not include the Optional Semi-Private Hospital Accommodation benefit. Please refer to the
Optional Semi-Private rate table for the additional premium required.
Saskatchewan,
Manitoba,
Northwest Territories,
Yukon Territory and
Nunavut
Alberta
British Columbia
P1
Ontario
New Brunswick,
Nova Scotia,
Prince Edward Island
and Newfoundland
Quebec
Age
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
0-44
$17
$33
$41
$23
$44
$56
$17
$33
$41
$24
$46
$60
$25
$48
$61
$24
$46
$60
45-54
$18
$35
$44
$25
$48
$61
$18
$35
$44
$26
$50
$65
$27
$52
$67
$26
$50
$65
55-64
$19
$37
$47
$26
$50
$65
$19
$37
$47
$28
$54
$70
$29
$56
$72
$28
$54
$70
65+
$20
$38
$49
$27
$52
$67
$20
$38
$49
$30
$56
$75
$31
$59
$76
$30
$56
$75
Age
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
0-44
$41
$79
$114
$45
$85
$123
$33
$63
$90
$51
$96
$137
NA
$44
$83
$121
45-54
$43
$82
$118
$47
$89
$126
$35
$66
$95
$53
$101
$143
NA
$45
$85
$123
55-64
$45
$85
$123
$49
$92
$131
$37
$70
$98
$56
$106
$150
NA
$47
$89
$126
65+
$46
$87
$125
$51
$96
$137
$39
$74
$101
$58
$108
$155
NA
$49
$92
$131
Age
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
0-44
$56
$107
$160
$60
$115
$171
$41
$79
$116
$64
$123
$182
$58
$113
$164
$51
$98
$144
45-54
$59
$112
$168
$63
$122
$179
$44
$85
$125
$68
$130
$194
$58
$113
$164
$53
$103
$150
55-64
$60
$115
$171
$66
$128
$184
$45
$85
$127
$70
$135
$199
$60
$115
$171
$56
$107
$160
65+
$60
$115
$171
$66
$128
$184
$45
$85
$127
$68
$130
$194
$60
$115
$171
$56
$107
$160
Pri
P2
P3
Optional Semi-Private Hospital Accommodation Monthly Rates
Rates and/or benefits are subject to change with thirty (30) days notice to the applicant/policy holder.
NOTE: The appropriate Semi-Private monthly rate below must be added to one of the plans above (P1, P2 or P3) if you wish to have the
Optional Semi-Private Hospital Accommodation as a benefit.
Age
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
0-44
$4
$6
$8
$5
$7
$9
$4
$6
$8
$6
$8
$10
$6
$8
$10
$5
$7
$9
45-54
$6
$8
$10
$7
$9
$11
$6
$8
$10
$8
$10
$12
$8
$10
$12
$7
$9
$11
55-64
$8
$10
$12
$9
$11
$14
$8
$10
$12
$10
$12
$15
$10
$12
$15
$9
$11
$14
65+
$12
$18
$21
$16
$23
$27
$12
$18
$21
$18
$27
$31
$18
$27
$31
$16
$23
$27
Wh