Prism Spectra Benefits
S1
S2
S3
$3,000 per year
Paid at 90%
Brand name drugs covered if no generic
equivalent is available
$3,000 per year
Paid at 90%
Brand name drugs covered if no generic
equivalent is available
$5,000 per year
Paid at 90%
Brand name drugs covered if no generic
equivalent is available
DENTAL - Combined maximums
per person for Schedules A, B & C
(if applicable)
Not covered
$500 in the first 12 months
$750 in the next 12 months
$1,000 every 12 months thereafter
$1,000 in the first 12 months
$1,000 in the next 12 months
$1,250 every 12 months thereafter
Schedule A – Basic
Not covered
Paid at 80%
Paid at 80%
Not covered
Paid at 60% in the first 12 months
Paid at 70% in the next 12 months
Paid at 80% thereafter
Paid at 80%
NOTE: Excludes vitamins, pa
cessation products, er
Not covered
Paid at 50%, starting in the
3rd benefit year
Paid at 50%, starting in the
3rd benefit year
DENTAL
Vision - maximum per person
$150 every 24 months
$150 in the first 24 months
$200 in the next 24 months
$300 every 24 months thereafter
$150 in the first 24 months
$200 in the next 24 months
$300 every 24 months thereafter
Accidental Dental - maximum per person
$5,000 per year
$5,000 per year
$10,000 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 in the first 4 years
$500 every 4 years thereafter
$500 every 3 years
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 in the first 12 months
$2,500 in the next 12 months
$5,000 every 12 months thereafter
$5,000 per year
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 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
$5,000 per year
foot orthotics - $250 every 24 months
stockings - 2 pairs every 4 months
surgical brassieres - 2 every 12 months
Covered
$50 every 24 months
Covered
$65 every 24 months
Covered
$65 every 24 months
Please see “Benefit Descriptions”
for more details
PRESCRIPTION DRUGS - maximum
per person
Schedule B – Basic Comprehensive
Schedule C – Major Services
PRESCRIPTION DRU
Prescription drugs/medication
prescription by law.
Schedule A – Basic
EXTENDED HEALTH
Medical Services
Eye examinations - maximum per person
$20 per visit; 20 visits per year
$400 per year
$20 per visit; 20 visits per year
$400 per year
$30 per visit; 20 visits per year
$600 per year
TRAVEL - maximum per person
[available up to age 65]
$1,000,000 per year
10 days per trip
$1,000,000 per year
15 days per trip
$1,000,000 per year
15 days per trip
Optional benefit - medical
questionnaire required
- maximum per person
NOTE: Optional Benefit – Additional premium required, please refer to pages (6) and (7)
$200 per day, 30 days per year
1
Schedule B – Basic Compr
• Periodontal treatment inclu
treatment of gums and tiss
• Endodontics – root canal th
• Denture cleaning, repairs, r
Schedule C – Major Servic
• Dentures
• Standard crown restoration
• Standard bridges, including
• Standard repair or recemen
NOTE: All of the dental bene
Association fee guide
Professional/Registered Therapists
- maximums per practitioner per person
• Chiropractor, Footcare Specialist
(Chiropodist/Podiatrist), Naturopath,
Osteopath, Physiotherapist,
Massage Therapist, Acupuncturist
• Psychologist, Speech Therapist
SEMI-PRIVATE HOSPITAL ACCOMMODATION
• Preventative cleaning and p
• Routine examinations, x-ra
• Fluoride treatments for chil
• Fillings and extractions
• Pit and fissure sealants
• Space maintainers and gen
$200 per day, 30 days per year
$200 per day, 30 days per year
2
Prism
This brochure outlines ben
terms, conditions, limitatio
Green Shield Canada upon
Benefit
Descriptions
Benefit
Descriptions
Benefit
Benefit
Benefit
Descriptions
Descriptions
Descriptions
PRESCRIPTION DRUGS
EXTENDED HEALTH
Medical Services
Prescription drugs/medications that have been approved for use in Canada that require a
PTION
PRESCRIPTION
DRUGS
PRESCRIPTION
DRUGS
DRUGS
EXTENDED
EXTENDED
HEALTH Vision
HEALTH
EXTENDED HEALTH
prescription by law.
Prescription eye glasses, contact lenses, laser eye surgery or replacement parts to
prescription eye glasses.
drugs/medications
Prescription drugs/medications
Prescription
that have been
drugs/medications
thatapproved
have been
for approved
use
that
in have
Canada
forbeen
usethat
in
approved
Canada
require afor
thatuse
require
in Canada
a
that requireVision
a
Vision
Vision
NOTE: Excludes vitamins, patent or proprietary medicines, over-the-counter drugs, smoking
by
prescription
law.
by law.
prescription by law.
Prescription eye
Prescription
glasses, contact
eye glasses,
Prescription
lenses,
contact
laser
eyeeye
lenses,
glasses,
surgery
laser
contact
oreye
replacement
surgery
lenses,or
laser
parts
replacement
eyetosurgery
parts
or replacement
to
parts to
cessation products, erectile dysfunction (ED) agents, fertility and obesity drugs.
NOTE: For information regarding eye examinations please see description under
prescription eye
prescription
glasses. eye glasses.
prescription eye glasses.
Medical Services.
des
NOTE:
vitamins,
Excludes
patent
vitamins,
NOTE:
or proprietary
Excludes
patent orvitamins,
medicines,
proprietary
patent
over-the-counter
medicines,
or proprietary
over-the-counter
drugs,
medicines,
smoking
drugs,
over-the-counter
smoking drugs, smoking
DENTAL
Includes diagnostic tests and x-rays, dialysis equipment, laboratory tests, radioactive t
and eye examinations.
Medical Services
Medical ServicesMedical Services
Includes diagnostic
Includes
tests
diagnostic
and x-rays,
Includes
testsdialysis
and
diagnostic
x-rays,
equipment,
dialysis
tests and
laboratory
equipment,
x-rays, tests,
dialysis
laboratory
radioactive
equipment,
tests,treatments
radioactive
laboratory treatments
tests, radioactive
NOTE: Eye examinations are available only in those provinces where eye examinatio
and eye examinations.
and eye examinations.
and eye examinations.
covered by the provincial government health plan on an annual basis.
NOTE: Eye examinations
NOTE: Eye examinations
are available
NOTE: Eye
are
onlyavailable
examinations
in those only
provinces
are
in those
available
where
provinces
eye
onlyexaminations
inwhere
thoseeye
provinces
examinations
are notwhere eye
are not
examinati
tion products,
cessation
erectile
products,
dysfunction
cessation
erectile(ED)
dysfunction
products,
agents,erectile
fertility
(ED) agents,
dysfunction
and obesity
fertility
(ED)
drugs.
and
agents,
obesityfertility
drugs.and obesity drugs. NOTE: For information
NOTE: Forregarding
NOTE:
information
eyeregarding
examinations
For information
eye examinations
please
regarding
see description
eye
please
examinations
seeunder
description
please
under
see description under
Professional/Registered Therapists
Accidental Dental
covered by the
covered
provincial
by the
government
provincial
coveredhealth
government
by theplan
provincial
on
health
an government
annual
plan on
basis.
an health
annualplan
basis.
on an annual basis.
Medical Services.
Medical Services. Medical Services.
Chiropractor, Footcare Specialists (Chiropodist/Podiatrist), Naturopath, Osteopath,
A – Basic
The repair or replacement of natural teeth which were damaged as a result of an accident to the
DENTAL Schedule
DENTAL
Physiotherapist, Psychologist, Speech Therapist, Acupuncturist and Registered
• Preventative cleaning and polishing (every 9 months)
mouth (blow to the mouth).
Professional/Registered
Professional/Registered
Therapists
Professional/Registered
Therapists
Therapists
Accidental Dental
Accidental Dental
Accidental Dental
Massage Therapist (RMT).
• Routine examinations, x-rays
Chiropractor,
Footcare Specialists
Footcare
Chiropractor,
(Chiropodist/Podiatrist),
Specialists
Footcare
(Chiropodist/Podiatrist),
Specialists
Naturopath,
(Chiropodist/Podiatrist),
Osteopath,
Naturopath, Osteopath,
Naturopath, Osteopath,
Schedule
– Basic A – Basic
Schedule A – Basic
The repair or The
replacement
repair or of
replacement
natural
The repair
teeth
of or
natural
which
replacement
were
teethdamaged
which
of natural
were
as teeth
adamaged
result
which
ofas
anwere
aaccident
result
damaged
oftoanthe
accident
as a result
to the
of an accident
to the Chiropractor,
• Fluoride treatments for children
NOTE: Damage to teeth as a result of eating something is not covered.
Physiotherapist,
Physiotherapist,
Psychologist, Psychologist,
Speech
Physiotherapist,
Therapist,
Speech
Psychologist,
Acupuncturist
Therapist, Acupuncturist
Speech
and Registered
Therapist,
andAcupuncturist
Registered and Registered
•e cleaning
Preventative
and cleaning
polishing
• Preventative
and
(every
polishing
9cleaning
months)
(every
and9 polishing
months) (every 9 months)
mouth (blow mouth
to the mouth).
(blow to the
mouth
mouth).
(blow to the mouth).
NOTE: All of the Extended Health benefits are not payable for services and supplies
• Fillings and extractions
Massage Therapist
Massage
(RMT).
TherapistMassage
(RMT). Therapist (RMT).
aminations,
• Routine examinations,
x-rays • Routine
x-rays
examinations, x-rays
a chronic care or psychiatric hospital or institution, chronic care unit of a gen
• Pit and fissure sealants
Ambulance Transportation
eatments
• Fluoridefortreatments
children
• Fluoride
for children
treatments for children
NOTE: Damage
NOTE:
to teeth
Damage
as a to
result
NOTE:
teethofas
Damage
eating
a result
something
toofteeth
eating
asis something
anot
result
covered.
of eating
is not something
covered. is not covered.
or when a patient is confined to a nursing home or home for the aged and re
• Space maintainers and general anaesthetics
When
required
as
the
result
of
an
accident
or
acute
physical
disability,
professional
land
or
air
NOTE: All of NOTE:
the Extended
All of the
Health
Extended
NOTE:
benefits
AllHealth
ofare
thenot
benefits
Extended
payable
areHealth
for
notservices
payable
benefits
and
forare
supplies
services
not payable
and
provided
supplies
for services
in provided
and supplies
in
d•extractions
Fillings and extractions
• Fillings and extractions
provincial government assistance.
ambulance to the nearest hospital equipped to provide the required treatment.
a chronic carea or
chronic
psychiatric
care orhospital
psychiatric
a chronic
or institution,
care
hospital
or psychiatric
orchronic
institution,
care
hospital
unit
chronic
or
of institution,
acare
general
unit hospital,
ofchronic
a general
care hospital,
unit of a ge
•urePitsealants
and fissure sealants
• Pit and fissure sealants
Ambulance Ambulance
Transportation
Transportation
Ambulance Transportation
Schedule B – Basic Comprehensive
or when
is confined
a patienttoorisawhen
confined
nursing
a patient
home
to a nursing
or
is confined
home
home
fortothe
orahome
aged
nursing
for
andhome
the
receives
aged
or home
and receives
for the aged and
ntainers
• Spaceand
maintainers
general
• Space
anaesthetics
and general
maintainers
anaesthetics
and general anaesthetics
When required
When
as the
required
result as
of When
an
theaccident
result
required
oforanacute
asaccident
thephysical
result
or acute
ofdisability,
an physical
accident
professional
disability,
or acute physical
land
professional
or air
disability,
land or
professional
air
land or airor when a patient
TRAVEL
• Periodontal treatment including: cleaning and scaling (8 units every 12 months) –
Hearing Aids
provincial government
provincial assistance.
government
provincial
assistance.
government assistance.
ambulance toambulance
the nearesttohospital
the ambulance
nearest
equipped
hospital
to to
theprovide
equipped
nearestthe
hospital
torequired
provide
equipped
treatment.
the required
to provide
treatment.
the required treatment.
treatment of gums and tissues of the mouth
Standard hearing aids, repairs or replacement parts.
Schedule
– Basic Comprehensive
B – Basic
Schedule
Comprehensive
B – Basic Comprehensive
that are required as a result of emergency illness or injuries which occurred
• Endodontics – root canal therapy
TRAVEL TRAVEL Services
TRAVEL
l•treatment
Periodontal
including:
treatment
• Periodontal
cleaning
including:
and
treatment
cleaning
scaling including:
(8and
units
scaling
every
cleaning
(812units
months)
andevery
scaling
–12 months)
(8 units every
–
12 months) – Hearing AidsHearing Aids Hearing Aids
you were vacationing or traveling for other than health reasons. Covers hospital serv
• Denture cleaning, repairs, rebasing and relining
NOTE:
Does
not
include
the
replacement
cost
for
batteries.
of treatment
gums and of
tissues
gumstreatment
ofand
thetissues
mouth
of gums
of the and
mouth
tissues of the mouth
Standard hearing
Standard
aids, hearing
repairs or
aids,
Standard
replacement
repairs
hearing
or parts.
replacement
aids, repairs
parts.
or replacement parts.
and accommodation, medical/surgical services, emergency transportation, repatriation
Services that Services
are required
that as
arearequired
Services
result ofas
that
emergency
a result
are required
ofillness
emergency
asorainjuries
result
illness
of
which
emergency
or injuries
occurred
which
illness
while
occurred
or injuries
while
which occurred
•s –Endodontics
root canal therapy
– root
• Endodontics
canal therapy
– root canal therapy
air ambulance.
Schedule C – Major Services
Home
Support
Services
you were vacationing
you wereorvacationing
traveling
youfor
or
were
other
traveling
vacationing
thanforhealth
other
or reasons.
traveling
than health
Covers
for other
reasons.
hospital
than
Covers
health
services
hospital
reasons.services
Covers hospital ser
eaning,
• Denture
repairs,
cleaning,
rebasing
• Denture
repairs,
andrebasing
cleaning,
relining and
repairs,
relining
rebasing and relining
NOTE: Does NOTE:
not include
Doesthe
notreplacement
include
NOTE: the
Does
cost
replacement
notforinclude
batteries.
cost
the for
replacement
batteries. cost for batteries.
• Dentures
Services of a Registered Nurse (RN), Registered Practical Nurse (RPN), or Licensed Practical
Nurse
and accommodation,
and accommodation,
medical/surgical
andmedical/surgical
accommodation,
services, emergency
services,
medical/surgical
transportation,
emergency
services,
transportation,
repatriation
emergency
and
repatriation
transportation,
and repatriatio
NOTE: Travel Benefits are not available after the age of 65.
• Standard crown restorations or onlays on natural teeth
(LPN) in the home when certified medically necessary by the attending physician.
air ambulance.
air ambulance. air ambulance.
Schedule
– Major Services
C – Major
Schedule
Services
C – Major Services
Home Support
Home
Services
Support Services
Home Support Services
• Standard bridges, including pontics, abutment retainers/crowns on natural teeth
• Dentures
• Dentures
Services of a Services
Registered
of aNurse
Registered
(RN),
Services
Registered
Nurse
of a (RN),
Registered
Practical
Registered
Nurse
Nurse
Practical
(RN),
(RPN),
Registered
Nurse
or Licensed
(RPN),
Practical
Practical
or Licensed
Nurse
Nurse
(RPN),
Practical
or Licensed
Nurse Practical Nurse
SEMI-PRIVATE
HOSPITAL
ACCOMMODATION
• Standard repair or recementing of crowns, onlays and bridgework on natural teeth
Medical Items
NOTE: TravelNOTE:
Benefits
Travel
are not
Benefits
available
NOTE:
areTravel
not
afteravailable
Benefits
the ageafter
are
of 65.
not
theavailable
age of 65.
after the age of 65.
rown
• Standard
restorations
crown •or
restorations
Standard
onlays oncrown
or
natural
onlays
restorations
teeth
on natural
or onlays
teeth on natural teeth
(LPN) in the home
(LPN) when
in the certified
home(LPN)
when
medically
incertified
the home
necessary
medically
whenbycertified
necessary
the attending
medically
by the
physician.
attending
necessaryphysician.
by the attending physician.
•
Aids
for
daily
living
include:
hospital
style
beds
including
rails
and
mattress,
decubitus
•ridges,
Standard
including
bridges,
pontics,
• Standard
including
abutment
bridges,
pontics,
retainers/crowns
including
abutmentpontics,
retainers/crowns
on natural
abutment
teeth
on
retainers/crowns
natural teeth on natural teeth
This benefit pays for the difference in cost between standard ward and semi-private
(ulcer care) supplies, trapeze
SEMI-PRIVATE
SEMI-PRIVATE
HOSPITAL
SEMI-PRIVATE
HOSPITAL
ACCOMMODATION
ACCOMMODATION
HOSPITAL ACCOMMODATION
epair
• Standard
or recementing
repair •orStandard
recementing
of crowns,
repair
onlays
of or
crowns,
recementing
and bridgework
onlays of
andcrowns,
on
bridgework
natural
onlays
teeth
onand
natural
bridgework
teeth on natural teeth Medical Items
Medical Items Medical Items
accommodation in a public or general (acute care) hospital when you have occupied
NOTE: All of the dental benefits are based on the current Provincial Dental
• Braces, casts, diabetic supplies (blood glucose monitor, lancets), catheter supplies,
• Aids for daily
• Aids
livingforinclude:
daily living
hospital
• Aids
include:
for
style
daily
hospital
beds
living
including
style
include:
beds
rails
hospital
including
and mattress,
style
railsbeds
and
decubitus
including
mattress,rails
decubitus
and mattress, decubitus
active
treatment
bed.
Your
provincial government health plan must accept or agree t
Association fee guide for general practitioners.
ostomy supplies, custom made foot orthotics
This benefit pays
This for
benefit
the difference
pays for
Thisthe
in
benefit
difference
cost between
pays in
forcost
the
standard
between
difference
ward
standard
inand
costsemi-private
between
ward andstandard
semi-private
ward and semi-private
(ulcer care) supplies,
(ulcer care)
trapeze
supplies,
(ulcer
trapeze
care) supplies, trapeze
pay the standard ward rate.
• Mobility Aids include: cane, crutch, walker, wheelchair, traction equipment
accommodation
accommodation
in
a
public
or
in
general
accommodation
a
public
(acute
or
general
care)
in
a
hospital
(acute
public
care)
orwhen
general
hospital
you (acute
have
when
occupied
care)
youhospital
have
an occupied
when you
an have occupie
NOTE:
NOTE:
the dental
All ofbenefits
the dental
are based
benefits
All ofon
the
are
the
dental
based
current
benefits
onProvincial
the current
are based
Dental
Provincial
on the current
Dental Provincial Dental
• Braces, casts,
• Braces,
diabeticcasts,
supplies
diabetic
• Braces,
(blood
supplies
glucose
casts,(blood
diabetic
monitor,
glucose
supplies
lancets),
monitor,
(blood
catheter
lancets),
glucose
supplies,
catheter
monitor, supplies,
lancets), catheter supplies,
• Prosthetics include: artificial limbs, eyes, prosthetic accessories, modifications and repairs,
active treatment
active
bed.
treatment
Your provincial
bed.
active
Your
government
treatment
provincial
bed.
health
government
Yourplan
provincial
must
health
accept
government
plan or
must
agree
accept
health
to or
plan
agree
musttoaccept or agree
iation fee
Association
guide for fee
general
guide
Association
practitioners.
for general
fee practitioners.
guide for general practitioners.
ostomy supplies,
ostomy
custom
supplies,
madecustom
ostomy
foot orthotics
made
supplies,
footcustom
orthotics
made foot orthotics
NOTE: • The semi-private benefit cannot be purchased on its own.
surgical brassieres after a mastectomy
pay the standard
pay the
ward
standard
rate. ward
pay the
rate.
standard ward rate.
• Mobility Aids
• Mobility
include: Aids
cane,include:
crutch,
• Mobility
cane,
walker,
Aids
crutch,
wheelchair,
include:
walker,
cane,
traction
wheelchair,
crutch,
equipment
walker,
traction
wheelchair,
equipmenttraction equipment
• This benefit does not apply to accommodation in a long-term care facility
Prism
• Respiratory Cardiology includes: continuous positive airway pressure pump (CPAP), apnea
• Prosthetics •include:
Prosthetics
artificial
include:
limbs,
• Prosthetics
artificial
eyes, prosthetic
limbs,
include:
eyes,
artificial
accessories,
prosthetic
limbs,
modifications
accessories,
eyes, prosthetic
modifications
and repairs,
accessories,
and modifications
repairs,
and repairs,
(i.e. chronic care facility/hospital), private hospital or program treatment fa
This brochure outlines benefits available. This is not a contract. Actual details,
monitor for respiratory disrhythmias (for infants), compressor, inhalant devices, tracheotomy
NOTE: • TheNOTE:
• The benefit
NOTE:
•benefit
semi-private
semi-private
cannot
The
be semi-private
purchased
cannot beonbenefit
purchased
its own.
cannot
on its
beown.
purchased on its own.
surgical brassieres
surgical
after
brassieres
a mastectomy
surgical
after a mastectomy
brassieres after a mastectomy
• Benefits are not payable for hospitalization due to pregnancy or pregnancy
terms, conditions, limitations and exclusions are detailed in the policy issued by
supplies, oxygen
This benefit
not apply
does
to• accommodation
not
Thisapply
benefit
to does
accommodation
innot
a long-term
apply toinaccommodation
care
a long-term
facility careinfacility
a long-term care facility
Prism
Prism
• Respiratory•Cardiology
Respiratoryincludes:
Cardiology
• Respiratory
continuous
includes:
Cardiology
positive
continuous
airway
includes:
positive
pressure
continuous
airway
pump
pressure
positive
(CPAP),pump
apnea
airway
(CPAP),
pressure
apnea
pump (CPAP), apnea • This benefit•does
conditions
which
commence
during
the
first ten (10) month period followin
Green Shield Canada upon application approval.
• Vascular compression includes: intermittent compression pump and sleeve, pressure gradient (i.e. chronic care
(i.e. facility/hospital),
chronic care facility/hospital),
(i.e.private
chronichospital
careprivate
facility/hospital),
or program
hospitaltreatment
orprivate
program
hospital
facility.
treatment
or program
facility. treatment f
ureThis
outlines
brochure
benefits
outlines
This
available.
brochure
benefits
Thisavailable.
outlines
is not a benefits
contract.
This is not
available.
Actual
a contract.
details,
This Actual
is not adetails,
contract. Actual details,
monitor for respiratory
monitor fordisrhythmias
respiratory
monitor
disrhythmias
(forfor
infants),
respiratory
compressor,
(for infants),
disrhythmias
inhalant
compressor,
(fordevices,
infants),
inhalant
tracheotomy
compressor,
devices, tracheotomy
inhalant devices, tracheotomy
effective
date
of
the
coverage.
surgical stockings
• Benefits are• not
Benefits
payable
are for
nothospitalization
•payable
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Prism Spectra® - Monthly Rates Effective January 1, 2008
P
Rates and/or benefits are subject to change with thirty (30) days notice to the applicant/policy holder.
NOTE: Prism Spectra 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
S1
Ontario
Quebec
Age
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
0-44
$37
$70
$97
$46
$86
$121
$37
$70
$97
$54
$103
$142
45-54
$42
$80
$113
$54
$103
$142
$42
$80
$113
$62
$119
55-64
$53
$100
$139
$64
$122
$172
$53
$100
$139
$77
65+
$28
$52
$67
$37
$70
$88
$28
$52
$67
$68
New Brunswick,
Nova Scotia,
Prince Edward Island
and Newfoundland
Single
Couple
Family
NA
$52
$100
$139
$167
NA
$59
$113
$160
$148
$207
NA
$73
$140
$198
$129
$160
NA
$40
$76
$95
P
S2
Age
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
0-44
$76
$143
$208
$82
$157
$227
$62
$117
$168
$94
$178
$263
NA
$80
$152
$218
45-54
$82
$157
$227
$92
$175
$255
$68
$130
$185
$104
$201
$294
NA
$90
$172
$242
55-64
$94
$180
$260
$104
$199
$288
$77
$146
$210
$122
$232
$343
NA
$105
$199
$284
65+
$67
$128
$173
$75
$142
$196
$52
$99
$136
$108
$207
$270
NA
$69
$131
$173
Age
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
Single
Couple
Family
0-44
$94
$179
$247
$106
$201
$274
$78
$150
$199
$120
$231
$310
NA
$106
$200
$266
45-54
$99
$192
$265
$113
$215
$295
$83
$160
$216
$131
$249
$337
NA
$114
$216
$290
55-64
$118
$227
$299
$134
$255
$336
$100
$194
$248
$157
$299
$386
NA
$139
$264
$333
65+
$83
$157
$217
$93
$174
$238
$66
$126
$168
$151
$288
$361
NA
$89
$168
$221
S3
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 (S1, S2 or S3) 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
0-44
$4
$6
$8
$5
$7
$9
$4
$6
$8
$6
$8
$10
45-54
$6
$8
$10
$7
$9
$11
$6
$8
$10
$8
$10
55-64
$8
$10
$12
$9
$11
$14
$8
$10
$12
$10
65+
$12
$18
$21
$16
$23
$27
$12
$18
$21
$18
Single
Couple
Family
NA
$5
$7
$9
$12
NA
$7
$9
$11
$12
$15
NA
$9
$11
$14
$27
$31
NA
$16
$23
$27
N
W