O .P .P . AS S O C IAT I O N M E M BE R S ’
G RE AT WE S T L IF E A S S U R AN C E C O M P A NY B E NE F I T
COV ERAGE
E F F E C T IV E AU G U S T 1 , 2 0 0 6
I MP O RT A NT C H AN G E S A S O F J U L Y 1 , 2 0 0 9
IMPORTANT CHANGES AS OF JULY 1, 2009
Inside This Issue
1 Important Changes as July 2009
2 Important Things to Remember
2 Drug and Medicine Expenses
2 Mandatory Generic Prescription
3 Other Supplementary Health
And Hospital Expenses Covered
4 Limited Expenses Covered
5 Dental Insurance
7 The Dental Plan Pays 60%
8 OPP (Employer) Life Insurance
8 OPPA Life Insurance Plans
As of July 1, 2009 Target Benefit Administrators (TBA) will be administering your
benefits on behalf of the OPPA through Great West Life Assurance (GWL).
There have been no changes to your health/vision/hearing/dental plans through
this transition and the carrier remains to be Great West Life Assurance.
Member’s existing claims and annual coverage amounts will be carried over to
the new plan. This means that members who purchased eyeglasses for $340 on
May 15, 2009 will not be eligible for new eyeglasses until May 15, 2011 as this is
the eligible amount for vision care in any consecutive 24-month period. The
same applies for all other benefit maximums such as paramedical or dental
benefits.
Detailed benefit information about your life and accidental death and
dismemberment insurance, health, vision/hearing, drug and dental benefits is
available on the OPPA Benefits website which is accessed through www.oppa.ca
on the member’s only area of our website. After OPPA members enter their user
name and password to gain access to the members only area, they will click on
the “Members Benefit” button to access benefit information.
A new OPP Association Group Insurance form, Evidence of Insurability form,
GWL Claim forms are available on-line.
TBA can be contacted on their OPPA designated toll-free number at 1-888-6606055 or 416-740-1335 which will be operational Monday to Friday from 8:30 to
5:00 or via e-mail at [email protected].
Member Benefit Services
Via www.oppa.ca
Members only site
GREAT WEST LIFE CLAIM INQUIRIES:
Members will still contact GWL directly at 1-800-461-6090 or by visiting the GWL
website at www.greatwestlife.com to make inquiries about the status of a claim
and to access claim history.
NEW DRUG CARDS:
New Drug Cards were mailed to all active, retired and surviving members in June
which are effective July 1, 2009. TBA should be contacted if updates to drug
card information are necessary.
UPDATING DEPENDENT/BENEFICIARY/MARITAL STATUS:
Target Benefit
Administrators
1-888-660-6055
or
416-740-1335.
Effective July 1, 2009, all active, retired or surviving members (if applicable) will
update their dependent, beneficiary or marital status on a new OPP Association
Group Insurance Form. This new form will replace the Group Insurance
Application form currently used by the Employer and the Ontario Pension Board.
The new OPP Association Group Insurance form will be available on-line on the
Benefits area of the OPPA member’s only website or members may request the
form through Target Benefit Administrators at 1-888-660-6055 or 416-740-1335.
PAGE 2
OPP ASSOCIATION MEMBER BENEFITS
IMPORTANT THINGS TO REMEMBER
Active Members – Health & Dental Benefits Group Policy #44501
Active Members
Group Policy 044501.
Pensioners – Retirees &
Surviving Family
Members
Group Policy 006772
Pensioners – Retirees and Surviving Family Members – Health & Dental
Benefits Group Policy #006772
It is always advisable to submit a quote to Great West Life for any
expense over $200.00. Quotes may be submitted by mail to P.O. Box
4076, Station ‘A’, Toronto ON M5W 1M8 or by fax to (416) 440-0963.
Great West Life will reply in writing and advise what is eligible for
payment under the health or dental plan.
You may also obtain information on your benefits by calling Great West
Life at 1-800-461-6090 or logging onto their website at
www.greatwestlife.com; it is also advisable to document the information
received, name of the person you spoke to and date the information was
obtained.
DRUG AND MEDICINE EXPENSES
Supplementary Health and Hospital plan covers 90% of prescription
drugs for all active and retired members, dependents and surviving
family members with a Great West Life drug benefit card. When
purchasing your prescription drugs, you will be required to pay the 10%
portion and Great West Life will be billed electronically for the remaining
90%.
Effective January 1, 1998 there is an $8.00 Pharmacist
Dispensing Fee Cap for the Great West Life drug benefits for all active
and retired members, dependents and surviving family members. Nonprescription drugs (drugs that may be sold without a prescription) are not
covered by this plan.
.
Great West Life Website
www.greatwestlife.com
Mandatory Generic Prescription
Drug Substitution/Pricing
When purchasing a brand name drug for medical or other reasons,
the plan will reimburse based on the cost of the generic drug and
the member will pay the difference. However, if no generic
equivalent exists for a covered drug, the reimbursement will be
based on the brand name cost.
OPP ASSOCIATION MEMBER BENEFITS
PAGE 3
After attaining age 65, prescription drugs are covered by the Ontario Drug
Benefit (ODB) Plan. The ODB Plan has an annual deductible. A pharmacist
can submit the deductible for 90% reimbursement under the Great West Life
drug benefit card.
If there is a prescription drug that is not covered by the ODB Plan, members
may submit to Great West Life to see the drug is eligible under the Great
West Life Plan.
OTHER SUPPLEMENTARY HEALTH AND HOSPITAL (SH&H)
EXPENSES COVERED
•
Hospital Care
100 % coverage of a semi-private room and up to $200 per day
towards the cost of a private room.
•
Convalescent Hospital or Chronic Care Hospital
Same as above but limited to 120 days of confinement in a
calendar year for a person age 65 or over. Does not apply for
custodial care.
•
Out-Patient Treatment
Charges made by an approved hospital for outpatient treatment
(excluding physicians’ and special nursing fees) not covered by
OHIP.
•
Registered Nurses’ Care
Charges for private duty nursing in your home by a Registered
Nurse, Registered Nurse’s Assistant or Licensed Practical Nurse
provided that they meet the minimum qualifications for giving this
care. Coverage must be pre-approved by Great West Life.
•
Insulin Appliances and Supplies for Diabetics
•
•
•
•
Great West Life
1-800-461-6090
Insulin infusion pumps - $3,000.00 per five (5) consecutive
years.
Medijector or precijet – reasonable and customary cost of one
per five (5) consecutive years.
Blood glucose monitoring machines (glucometer) – reasonable
and customary costs for the purchase and/or repairs of one
machine per person per consecutive three (3) year period.
100% of reasonable and customary costs of supplies related to
the use of the above-referenced diabetic appliances; these
supply costs shall not be subject to appliance maximums.
PAGE 4
OPP ASSOCIATION MEMBER BENEFITS
•
Artificial limbs and eyes, crutches, splints, casts, trusses and braces
All covered under SH&H.
•
Dental services and dental supplies following an accident
SH&H will cover expenses provided by a dental surgeon within a 12-month
period immediately following an accident. (Expenses are limited to costs
incurred for damages to natural teeth). Expenses include replacement of
teeth and setting of a jaw fractured or dislocated in an accident.
•
Rental of wheel chair, hospital bed or iron lung required for temporary
therapeutic use
All covered under SH&H
•
Ambulance service to the nearest hospital (for emergency only)
All covered under SH&H, excluding OHIP-covered benefits.
For the above services, unless specified, there is no maximum limit for
expenses covered by SH&H except a $25,000 limited paid during the
person’s lifetime on expenses related to organ transplants.
LIMITED EXPENSES COVERED
•
Paramedical Services
Includes the services of a Chiropractor, Osteopath, Naturopath, Chiropodist,
Podiatrist,
Registered
Massage
Therapist,
Speech
Therapist,
Physiotherapist, or Acupuncturist. Services covered to a maximum of $35
per visit with an annual maximum of $1,200 per person for each type of
service. NOTE: this plan is only made eligible to those who have exhausted
any OHIP benefits covering these services.
•
Out-of-hospital licensed psychological treatment
Will cover visits, including family and group therapy, up to $50.00 per half
hour for individual psychotherapy and/or testing and $50.00 per hour for all
other visits (secondary patients) and sitting in for consultation. Coverage will
have an annual maximum of $1,500 for psychological treatment. Coverage
will also include services rendered by a Social Worker with a Master’s
Degree in Social Work or a qualified Psychiatrist, where such services are
equivalent to the services which would otherwise be provided by a
psychologist.
OPP ASSOCIATION MEMBER BENEFITS
PAGE 5
•
Vision Care
Spending Account of $340 for vision care within a consecutive 24-month
period. Eligible expenses include the purchase, fitting or repair of prescription
eyeglasses or contact lenses, laser surgery, eye exams (one per 24 months),
or any combination thereof. Maximum $340 for children 12 years old or
younger every consecutive 6-month period.
•
Hearing Aids
Up to $1,000 (maximum per person in any consecutive 3 year period)
towards expenses for purchase or repair of hearing aids (excluding
batteries).
•
Audiologist Testing
100% of the cost of one audiologist test in any consecutive 24-month period.
•
Orthopedic Shoes
75% of cost of one pair of custom made orthopaedic shoes or winter
footwear in any calendar year or 75% of the cost of repair to a maximum of
one repair in any calendar year. Maximum $500 per purchase if shoes are
custom made, Orthopedic sandals are not covered under this plan. Preapproval of orthopaedic shoes is recommended prior to purchase.
•
Orthotics
Orthotic lifts which are specially designed and constructed for the employee
or dependent and are prescribed by a medical doctor, chiropractor, podiatrist
or chiropodist. Claimants will be allowed one pair of orthotic lifts per year to
a maximum of $500. Pre-approval of orthotics is recommended prior to
purchase.
DENTAL INSURANCE
COSTS ARE COVERED ACCORDING TO A SET SCHEDULE OF FEES
AS SET OUT BY THE ONTARIO DENTAL ASSOCIATION AND IN
FORCE AT THE TIME OF EXPENSE. THE DENTAL PLAN PAYS 90%
OF THE COST (ACCORDING TO ONTARIO DENTAL ASSOCIATION
FEES SCHEDULE) FOR THE FOLLOWING BASIC DENTAL CARE
SERVICES:
Clinical Oral Examinations
•
Complete or new patient oral examinations once every 3 years
•
Recall oral examinations once every 9 months (except children 12
years of age and under every 6 months).
PAGE 6
OPP ASSOCIATION MEMBER BENEFITS
X-rays
•
Panoramic x-rays once every 3 years
•
Complete full month series of x-rays once every 2 years
•
Bite-wing x-rays once every 6 months
Preventative Services
•
Teeth cleaning, fluoride treatments are limited to eligible dependent
children only and oral hygiene instruction once every 6 months.
•
Pit and fissure adhesive sealants (adults and children) to one application
per tooth surface per lifetime.
Restorative Services
•
Amalgam, silicate, acrylic and composite fillings
•
Retentive pins
•
Temporary cement restorations
Surgical Services
•
Removal of erupted teeth (uncomplicated)
•
Surgical removal of teeth
Adjunctive General Services
•
Denture repairs, relines and rebases
•
Drugs, medications and injections given in the dentist’s office
•
General anaesthesia
•
Professional consultations and visits
Prosthodontics Services and Repairs
•
In office lab charges when applicable to the above procedures.
Endodontics Services
•
Pulp capping, pulpotomy, root canal therapy, apexification, periapical
services, root amputation and other endodontics procedures.
•
Hemisection
•
Bleaching (endodontically treated tooth)
•
Intentional removal, apical filling and replantation
•
Emergency procedures
Periodontal Services
•
Non-surgical services, surgical services and adjunctive periodontal
services.
OPP ASSOCIATION MEMBER BENEFITS
PAGE 7
THE DENTAL PLAN PAYS 60% OF THE COST
(ACCORDING TO ONTARIO DENTAL ASSOCIATION
FEES SCHEDULE) FOR THE FOLLOWING:
Denture Services
•
Complete dentures, upper and/or lower, once every 3 years
•
Partial dentures, once every 3 years
•
In office lab charges and diagnostic costs when applicable to the above
procedures
•
Repairs to existing bridgework not earlier than 3 months after insertion
Note: Your dental plan pays 90% of the cost according to Ontario Dental
Association Fees Schedule for denture repairs.
Orthodontic Services
•
Observation and adjustment
•
Orthodontic appliances
•
Preventative services
•
Diagnostic services
In office lab charges when applicable to the above procedures
Major Restorative Services
•
Such restorative services as gold foil restorations, metal inlay
restorations, retentive pins, etc.
•
Such prosthodonic services as evaluation of extensive restorative
dentistry, porcelain repair, pontics, etc.
•
In office lab charges and diagnostic costs when applicable to the above
procedures
Allowed combined annual maximum of $2,000 per family per calendar
year for dentures, orthodontics and major restorative services. If
treatment is expected to cost over $200, submit a treatment plan to
Great West Life. They will advise you the amount they will reimburse. If
treatment does not start within 90 days of the submitted plan, then a
new treatment plan must be filed.
PAGE 8
OPP ASSOCIATION MEMBER BENEFITS
OPP LIFE INSURANCE PLANS
BASIC LIFE - 1 x AMOUNT OF YOUR SALARY:
The Employer pays the premium for this policy. This policy reduces to
$2,000 paid-up insurance upon retirement at no cost to you.
OPTIONAL 1, 2, 3 x SALARY :
Remember to
Active Members- $0.10 THOUSAND/MONTH
Retired Members - $0.17 THOUSAND/MONTH
change your
beneficiary (ies) if
The amount of coverage for active members is based on your current rate
of salary. The amount of coverage for retirees is based on your salary at
the date of retirement. This policy continues to age 65 at which time it
terminates. The cost will be deducted from your payroll deposit or your
pension deposit.
you have any
change in status
DEPENDENT LIFE - One dependent [spouse or child] - $0.08/month
More than one dependent [spouse and child(ren)] $0.15/month
This policy is payable to the member upon death of the dependent. This
policy terminates upon retirement.
O. P .P. ASSOCIATION LIFE INSURANCE PLANS
A) BASIC LIFE, BASIC ACCIDENTAL DEATH & DISMEMBERMENT
(AD&D), and OPTIONAL DEPENDENT LIFE
•
•
•
•
•
•
•
B)
$6,000 Basic Life insurance on member only
$6,000 Basic Accidental Death and Dismemberment on member only
$6,000 Optional Dependent Life, if applied for, on spouse and on each
eligible child (up to age 21, or 25 if continuing education)
Premiums paid by O.P.P.A. until retirement
Premium after retirement is $3.38 monthly
At age 65, Basic Life becomes one paid up policy of $2,000 on retired
member only
Spouse covered until member attains the age of 65 and dependant
children until age 21/25 or the member attains age 65, whichever comes
first.
OPTIONAL
$10,000
DISMEMBERMENT
•
•
•
•
LIFE
and
ACCIDENTAL
DEATH
&
Voluntary - coverage on member only
Rate - $3.20 monthly (retiree) or $1.52 bi-weekly (active)
Terminates at age 65
Must be purchased to be eligible to apply for D) Optional AD&D and E)
Spousal below.
OPP ASSOCIATION MEMBER BENEFITS
C)
PAGE 9
G37997 $20,000 LIFE INSURANCE - $6.25/PAY
•
This policy is mandatory for active members. Coverage is on member only. This policy
may be continued when you retire at a cost of $13.50 per month and will be payable to
your beneficiary upon your death, regardless of your age.
D) OPTIONAL ACCIDENTAL DEATH & DISMEMBERMENT
• Policy terminates at member’s age 70.
• Family Coverage: Spouse is insured for 40% of benefits if you have dependent
children or for 50% if there are no dependent children. Dependent children are covered
for 10% of the benefit if you have a spouse for 15% if there is no spouse.
• Must have purchased B) Optional $10,000 Life and Accidental Death and
Dismemberment insurance to apply for this coverage. The $10,000 accidental death
and dismemberment component is replaced by the chosen amount of coverage under
the optional accidental death and dismemberment plan.
PRINCIPLE SUM
$ 250,000
225,000
200,000
175,000
150,000
125,000
100,000
75,000
50,000
E)
SINGLE
$ 15.00/month
13.50
12.00
10.50
9.00
7.50
6.00
4.50
3.00
FAMILY
$ 20.00/month
18.00
16.00
14.00
12.00
10.00
8.00
6.00
4.00
OPTIONAL SPOUSAL LIFE INSURANCE
• Must have purchased B) Optional $10,000 Life and Accidental Death and
Dismemberment insurance to apply for this coverage.
OPTION "A"
$30,000.00
Age Under 40 - $2.10/month
40 to 44 - $4.20/month
45 to 49 - $6.90/month
50 to 54 - $10.50/month
55 to 59 - $18.00/month
60 to 64 - $26.40/month
!
Age
OPTION "B"
$60,000.00
Under 40 - $4.20/month
40 to 44 - $8.40/month
45 to 49 - $13.80/month
50 to 54 - $21.00/month
55 to 59 - $36.00/month
60 to 64 - $52.80/month
When spouse attains age 65 the Spousal Life policy amount is reduced and
may be continued until spouse’s 70th birthday.
$15,000.00
65 to 69 - $19.95/month
$30,000.00
65 to 69 - $39.90/month