MBT BENEFITS

 

Please refer to Quick Chart

Quick Chart

MEMBER BENEFITS TRUST

CLASS – 2

OUTLINE OF BENEFITS

Services shown below will be eligible if they are usual, reasonable and customary, and are medically necessary for the treatment of an illness or injury.  Please contact the Member Benefits Trust at (604) 685-1678, or the Green Shield Customer Service Centre toll free at 1-888-711-1119 to determine benefit eligibility and coverage details.  Green Shield Canada’s Customer Service Centre is available 5:30 am to 4:30 pm Pacific Standard Time.

BENEFIT YEAR

• Your benefit year runs from June 1 to May 31 each year.  Where applicable, your deductible, co-pay and/or maximums will be calculated for this 12 month period each year.

DRUG

• A co-payment of 25% of the drug  cost plus the dispensing fee applies to each prescription.
• Your overall Drug maximum is $5,000 per participant, per calendar year. 
• Drugs are eligible only if the drug is a benefit of your current provincial medical plan.
• Drugs may be submitted on a Pay Direct basis at your pharmacy.
• Benefits include drugs legally requiring a prescription by law, diabetic needles and syringes.   
• Benefits do not include medication for the treatment of anti-obesity, erectile dysfunction, and fertility.  Serums and vitamins are also ineligible unless injected and medically necessary.
• Smoking cessation products are covered with a $200 lifetime maximum per person. Products available over the counter are ineligible.
• If you are a resident of Ontario, The Ontario Drug Benefit co-pay for seniors is not a benefit.
• In the province of Quebec, legislation states that Green Shield Canada is obligated to follow RAMQ reimbursement guidelines for all residents of Quebec. For those 65 years of age and under, Green Shield Canada is primary payor.

HEALTH SERVICES

• Your overall Health deductible is Nil.
• Your co-payment for Health Services is 5%.
• Co-payments do not apply to Accommodations, Vision, Audio and Travel Benefits.
• Co-payments apply to Emergency Transportation, Medical Items, Paramedical Services, Dental Accident, and Eye Exams.

EMERGENCY TRANSPORTATION

• Ambulance Transportation, for land or air ambulance to the nearest hospital equipped to provide the required treatment.

ACCIDENTAL DENTAL BENEFITS

• Accidental Dental benefits for treatment by a dentist.  A dental accident report form must be submitted immediately following the accident.

ACCOMMODATION

SEMI-PRIVATE

• Semi-Private Room in a public general hospital   

AUDIO

• Reimbursement will be made for standard hearing aids, repairs or replacement parts up to a maximum of $750 once every 5 years.
• Batteries are not eligible.

MEDICAL ITEMS

Prosthetic Appliances and Durable Medical Equipment as well as replacements, repairs, fittings and adjustments of such devices.  Contact the Customer Service Centre to verify eligibility of a particular benefit.

OPTOMETRIST EYE EXAMS

• Optometrist eye examinations performed by a licensed Optometrist limited to one exam up to a maximum of $65 per 24 months.  Applicable co-payment will be applied.  Note:  the Provincial Health Care Plan must be used first (where applicable).

PARAMEDICAL SERVICES

• Physiotherapist, Registered Clinical Psychologist, Registered Clinical Counselor, Registered Social Worker, Chiropractor, Osteopath, Podiatrist/Chiropodist, Naturopath, Registered Massage Therapist (medical referral required), Speech Therapist,  Acupuncturist (physician/surgeon or anyone licensed through the Acupuncture Foundation of Canada to perform acupuncture) up to a $500 maximum per paramedical discipline per benefit year (June 1 to May 31)

NOTE:

• The above listed paramedicals are subject to a combined overall maximum of $900, per participant, per benefit year (June 1 to May 31).
• All paramedical services, excluding Psychologist benefits, are subject to a maximum reimbursement of $30 per visit (June 1 to May 31). Applicable co-payment will apply.
• Paramedical services are only eligible when the practitioner rendering the service is licensed by their provincial association and that association is recognized by Green Shield Canada.  Please contact the Green Shield Customer Service Centre to confirm eligibility when in doubt.
• Private Duty Nursing Benefits carry a maximum of $15,000 per benefit year (June 1 to May 31) for the services of a registered nurse (R.N.) or registered nurses assistant (R.N.A.) in the home on a full or part shift basis.

VISION

• Your Vision Benefit carries a maximum of $250 every 24 months (or $250 every 12 months if a change in prescription occurs) for prescription eye glasses (including prescription sunglasses) and/or contact lenses and/or towards laser eye surgery provided they are dispensed by an Optometrist, an Optician or an Ophthalmologist.

Commencement of your benefit period is based on the initial date you receive vision benefits.  This service date is the actual pick-up date of the eyewear.

As a Green Shield subscriber, you have access to our national preferred provider vision network arrangement with “The Bay Optical” and “Zellers Vision Centre” stores.

All Green Shield subscribers are eligible to receive a discount of 33% off the regular prices available at “The Bay Optical” and “Zellers Vision Centres”. This offer applies to all extra coatings and upgrades. (Excludes disposable contact lenses).

Features of this great value-added service include:

• offer applies to any Green Shield subscriber, regardless of whether you have Green Shield vision benefits or not
• direct billing to Green Shield by the provider; the subscriber just pays any portion not covered
• trustworthy retail chains with convenient locations
• discount offer applies to everything such as coatings, upgrades and accessories
• hundreds of the latest frame styles to choose from plus latest lens and coating technology
• professional opticians to assist in selecting products
• offer applies to non-disposable contact lenses

To find a Bay Optical store near you, call the toll free store locator at 1-866-BAY-EYES. Or visit our web site at www.greenshield.ca

CLAIMING INFORMATION

• Present your Green Shield Identification Card as proof of being a Green Shield subscriber.
• The vision provider will apply the appropriate discount(s) to your claim and submit the claim directly to Green Shield for payment. You pay your vision provider any balance not covered under your vision benefit
• If no vision benefits exist, you pay your provider the full balance owing after the applicable discounts have been applied.

TRAVEL BENEFITS

• Travel Benefits are eligible within the first 90 days per trip while traveling or vacationing outside of the Province/Country.
• Canadian residents are covered while temporarily residing outside of the country provided they maintain their government health insurance plan coverage.  Note:  the 90 day per trip out-of-province/country travel limit would apply.  
• Your maximum is $1,000,000 per calendar year for Emergency Services; and $50,000 per calendar year for Referral Services. 
• Hospital and medical services are eligible only if your provincial government health plan provides payment toward the cost of the services received.
• Green Shield must be contacted by phone within 48 hours of commencement of treatment, by dialing 1-800-936-6226 within Canada or USA or call collect 0 519-742-3556.  These telephone assistance numbers are also located on the reverse of your Green Shield Identification Card.
• Green Shield, through consultation with the Assistance Medical Team, reserves the right to repatriate the patient for treatment upon medical verification of the tolerance for travel.  Carry your Green Shield identification card with you when traveling.

For complete details on your travel benefits, please refer to the enclosed Deluxe Travel Plan Booklet.

Top of Page

MEMBER BENEFITS TRUST

CLASS – 3

OUTLINE OF BENEFITS

Services shown below will be eligible if they are usual, reasonable and customary, and are medically necessary for the treatment of an illness or injury.  Please contact the Member Benefits Trust at (604) 685-1678, or the Green Shield Customer Service Centre toll free at 1-888-711-1119 to determine benefit eligibility and coverage details.  Green Shield Canada’s Customer Service Centre is available 5:30 am to 4:30 pm Pacific Standard Time.

BENEFIT YEAR

• Your benefit year runs from June 1 to May 31 each year.  Where applicable, your deductible, co-pay and/or maximums will be calculated for this 12 month period each year.

DRUG

• A co-payment of 25% of the drug cost plus the dispensing fee applies to each prescription.
• Your overall Drug maximum is $5,000 per participant, per calendar year. 
• Drugs are eligible only if the drug is a benefit of your current provincial medical plan.
• Drugs may be submitted on a Pay Direct basis at your pharmacy.
• Benefits include drugs legally requiring a prescription by law, diabetic needles and syringes.   
• Benefits do not include medication for the treatment of anti-obesity, erectile dysfunction, and fertility.  Serums and vitamins are also ineligible unless injected and medically necessary.
• Smoking cessation products are covered with a $200 lifetime maximum per person. Products available over the counter are ineligible.
• If you are a resident of Ontario, The Ontario Drug Benefit co-pay for seniors is not a benefit.
• In the province of Quebec, legislation states that Green Shield Canada is obligated to follow RAMQ reimbursement guidelines for all residents of Quebec. For those 65 years of age and under, Green Shield Canada is primary payor.

HEALTH SERVICES

• Your overall Health deductible is Nil.
• Your co-payment for Health Services is 5%.
• Co-payments do not apply to Accommodations, Vision, Audio and Travel Benefits.
• Co-payments apply to Emergency Transportation, Medical Items, Paramedical Services, Dental Accident, and Eye Exams.

EMERGENCY TRANSPORTATION

• Ambulance Transportation, for land or air ambulance to the nearest hospital equipped to provide the required treatment.

ACCIDENTAL DENTAL BENEFITS

• Accidental Dental benefits for treatment by a dentist.  A dental accident report form must be submitted immediately following the accident.

ACCOMMODATION

SEMI-PRIVATE

• Semi-Private Room in a public general hospital   

AUDIO

• Reimbursement will be made for standard hearing aids, repairs or replacement parts up to a maximum of $750 once every 5 years.
• Batteries are not eligible.

MEDICAL ITEMS

Prosthetic Appliances and Durable Medical Equipment as well as replacements, repairs, fittings and adjustments of such devices.  Contact the Customer Service Centre to verify eligibility of a particular benefit.

OPTOMETRIST EYE EXAMS

• Optometrist eye examinations performed by a licensed Optometrist limited to one exam up to a maximum of $65 per 24 months.  Applicable co-payment will be applied.  Note:  the Provincial Health Care Plan must be used first (where applicable).

PARAMEDICAL SERVICES

• Physiotherapist, Registered Clinical Psychologist, Registered Clinical Counselor, Registered Social Worker, Chiropractor, Osteopath, Podiatrist/Chiropodist, Naturopath, Registered Massage Therapist (medical referral required), Speech Therapist, Acupuncturist (physician/surgeon or anyone licensed through the Acupuncture Foundation of Canada to perform acupuncture) up to a $500 maximum per paramedical discipline per benefit year (June 1 to May 31)

NOTE:

• The above listed paramedicals are subject to a combined overall maximum of $900, per participant, per benefit year (June 1 to May 31).
• All paramedical services, excluding Psychologist benefits, are subject to a maximum reimbursement of $30 per visit (June 1 to May 31). Applicable co-payment will apply.
• Paramedical services are only eligible when the practitioner rendering the service is licensed by their provincial association and that association is recognized by Green Shield Canada.  Please contact the Green Shield Customer Service Centre to confirm eligibility when in doubt.
• Private Duty Nursing Benefits carry a maximum of $15,000 per benefit year (June 1 to May 31) for the services of a registered nurse (R.N.) or registered nurses assistant (R.N.A.) in the home on a full or part shift basis.

VISION

• Your Vision Benefit carries a maximum of $250 every 24 months (or $250 every 12 months if a change in prescription occurs) for prescription eye glasses (including prescription sunglasses) and/or contact lenses and/or towards laser eye surgery provided they are dispensed by an Optometrist, an Optician or an Ophthalmologist.

Commencement of your benefit period is based on the initial date you receive vision benefits.  This service date is the actual pick-up date of the eyewear.

As a Green Shield subscriber, you have access to our national preferred provider vision network arrangement with “The Bay Optical” and “Zellers Vision Centre” stores.

All Green Shield subscribers are eligible to receive a discount of 33% off the regular prices available at “The Bay Optical” and “Zellers Vision Centres”. This offer applies to all extra coatings and upgrades. (Excludes disposable contact lenses).

Features of this great value-added service include:

• offer applies to any Green Shield subscriber, regardless of whether you have Green Shield vision benefits or not
• direct billing to Green Shield by the provider; the subscriber just pays any portion not covered
• trustworthy retail chains with convenient locations
• discount offer applies to everything such as coatings, upgrades and accessories
• hundreds of the latest frame styles to choose from plus latest lens and coating technology
• professional opticians to assist in selecting products
• offer applies to non-disposable contact lenses

To find a Bay Optical store near you, call the toll free store locator at 1-866-BAY-EYES. Or visit our web site at www.greenshield.ca

CLAIMING INFORMATION

• Present your Green Shield Identification Card as proof of being a Green Shield subscriber.
• The vision provider will apply the appropriate discount(s) to your claim and submit the claim directly to Green Shield for payment. You pay your vision provider any balance not covered under your vision benefit
• If no vision benefits exist, you pay your provider the full balance owing after the applicable discounts have been applied.

DENTAL

• Your deductible is nil.
• Your overall Dental maximum is $500 per person, per benefit year (June 1 to May 31).
• Stated maximums are based on paid claims.
• Your co-insurance which is applied to the eligible allowed amount is 50% for Basic Services and 50% for Comprehensive Basic Services.
• Beginning on the date of the first paid claim, recalls are covered every 6 months, other exams and full mouth x-rays every 3 years.   
• Comprehensive Basic Services cover denture relines 1 every 3 years.
• Applicable lab, drug and other expenses are eligible to a maximum of 40% (50% cap on dentures) of the allowable professional fee. Any applicable co-payment is then applied.
• Your eligible claims are reimbursed at the level stated above and in accordance with the current Provincial Dental Association Fee Guide for General Practitioners. In provinces with more than one fee guide, Green Shield will reimburse according to the least expensive standard fee (or fee range).

BASIC SERVICES

• Recalls include exams, bitewing X-rays, preventive cleanings and fluoride treatments.
• Complete, general or comprehensive oral exams, full mouth x-rays and panoramic x-rays.
• Basic restorations, fillings and inlays.
• Extractions and surgical services. General anesthetics and intravenous sedation only when done in conjunction with eligible extraction(s) and/or oral surgery. Sleep dentistry is not eligible.

COMPREHENSIVE BASIC SERVICES

• Endodontic treatment including standard root canal therapy, excluding retreatments.
• Periodontal treatment including scaling and/or root planing.
• Standard denture services including relining and rebasing of dentures plus denture adjustments after 3 months from installation

TRAVEL BENEFITS

• Travel Benefits are eligible within the first 90 days per trip while traveling or vacationing outside of the Province/Country.
• Canadian residents are covered while temporarily residing outside of the country provided they maintain their government health insurance plan coverage.  Note:  the 90 day per trip out-of-province/country travel limit would apply.  
• Your maximum is $1,000,000 per calendar year for Emergency Services; and $50,000 per calendar year for Referral Services. 
• Hospital and medical services are eligible only if your provincial government health plan provides payment toward the cost of the services received.
• Green Shield must be contacted by phone within 48 hours of commencement of treatment, by dialing 1-800-936-6226 within Canada or USA or call collect 0 519-742-3556.  These telephone assistance numbers are also located on the reverse of your Green Shield Identification Card.
• Green Shield, through consultation with the Assistance Medical Team, reserves the right to repatriate the patient for treatment upon medical verification of the tolerance for travel.  Carry your Green Shield identification card with you when traveling.

For complete details on your travel benefits, please refer to the enclosed Deluxe Travel Plan Booklet.

Top of Page

MEMBER BENEFITS TRUST

CLASS - 4

OUTLINE OF BENEFITS

Services shown below will be eligible if they are usual, reasonable and customary, and are medically necessary for the treatment of an illness or injury.  Please contact the Member Benefits Trust at (604) 685-1678, or the Green Shield Customer Service Centre toll free at 1-888-711-1119 to determine benefit eligibility and coverage details.  Green Shield Canada’s Customer Service Centre is available 5:30 am to 4:30 pm Pacific Standard Time.

BENEFIT YEAR

• Your benefit year runs from June 1 to May 31 each year.  Where applicable, your deductible, co-pay and/or maximums will be calculated for this 12 month period each year.

DRUG

• A co-payment of 25% of the drug cost plus the dispensing fee applies to each prescription.
• Your overall Drug maximum is $5,000 per participant, per calendar year. 
• Drugs are eligible only if the drug is a benefit of your current provincial medical plan.
• Drugs may be submitted on a Pay Direct basis at your pharmacy.
• Benefits include drugs legally requiring a prescription by law, diabetic needles and syringes.   
• Benefits do not include medication for the treatment of anti-obesity, erectile dysfunction, and fertility.  Serums and vitamins are also ineligible unless injected and medically necessary.
• Smoking cessation products are covered with a $200 lifetime maximum per person. Products available over the counter are ineligible.
• If you are a resident of Ontario, The Ontario Drug Benefit co-pay for seniors is not a benefit.
• In the province of Quebec, legislation states that Green Shield Canada is obligated to follow RAMQ reimbursement guidelines for all residents of Quebec. For those 65 years of age and under, Green Shield Canada is primary payor.

HEALTH SERVICES

• Your overall Health deductible is Nil.
• Your co-payment for Health Services is 5%.
• Co-payments do not apply to Accommodations, Vision, Audio and Travel Benefits.
• Co-payments apply to Emergency Transportation, Medical Items, Paramedical Services, Dental Accident, and Eye Exams.

EMERGENCY TRANSPORTATION

• Ambulance Transportation, for land or air ambulance to the nearest hospital equipped to provide the required treatment.

ACCIDENTAL DENTAL BENEFITS

• Accidental Dental benefits for treatment by a dentist.  A dental accident report form must be submitted immediately following the accident.

ACCOMMODATION

SEMI-PRIVATE

• Semi-Private Room in a public general hospital   

AUDIO

• Reimbursement will be made for standard hearing aids, repairs or replacement parts up to a maximum of $750 once every 5 years.
• Batteries are not eligible.

MEDICAL ITEMS

Prosthetic Appliances and Durable Medical Equipment as well as replacements, repairs, fittings and adjustments of such devices.  Contact the Customer Service Centre to verify eligibility of a particular benefit.

OPTOMETRIST EYE EXAMS

• Optometrist eye examinations performed by a licensed Optometrist limited to one exam up to a maximum of $65 per 24 months.  Applicable co-payment will be applied.  Note:  the Provincial Health Care Plan must be used first (where applicable).

PARAMEDICAL SERVICES

• Physiotherapist, Registered Clinical Psychologist, Registered Clinical Counselor, Registered Social Worker, Chiropractor, Osteopath, Podiatrist/Chiropodist, Naturopath, Registered Massage Therapist (medical referral required), Speech Therapist, Acupuncturist (physician/surgeon or anyone licensed through the Acupuncture Foundation of Canada to perform acupuncture) up to a $500 maximum per paramedical discipline per benefit year ( June 1 to May 31)

NOTE:

• The above listed paramedicals are subject to a combined overall maximum of $900, per participant, per benefit year (June 1 to May 31).
• All paramedical services, excluding Psychologist benefits, are subject to a maximum reimbursement of $40 per visit (June 1 to May 31). Applicable co-payment will apply.
• Paramedical services are only eligible when the practitioner rendering the service is licensed by their provincial association and that association is recognized by Green Shield Canada.  Please contact the Green Shield Customer Service Centre to confirm eligibility when in doubt.
• Private Duty Nursing Benefits carry a maximum of $15,000 per benefit year (June 1 to May 31) for the services of a registered nurse (R.N.) or registered nurses assistant (R.N.A.) in the home on a full or part shift basis.

VISION

• Your Vision Benefit carries a maximum of $250 every 24 months (or $250 every 12 months if a change in prescription occurs) for prescription eye glasses (including prescription sunglasses) and/or contact lenses and/or towards laser eye surgery provided they are dispensed by an Optometrist, an Optician or an Ophthalmologist.

Commencement of your benefit period is based on the initial date you receive vision benefits.  This service date is the actual pick-up date of the eyewear.

As a Green Shield subscriber, you have access to our national preferred provider vision network arrangement with “The Bay Optical” and “Zellers Vision Centre” stores.

All Green Shield subscribers are eligible to receive a discount of 33% off the regular prices available at “The Bay Optical” and “Zellers Vision Centres”. This offer applies to all extra coatings and upgrades. (Excludes disposable contact lenses).

Features of this great value-added service include:

• offer applies to any Green Shield subscriber, regardless of whether you have Green Shield vision benefits or not
• direct billing to Green Shield by the provider; the subscriber just pays any portion not covered
• trustworthy retail chains with convenient locations
• discount offer applies to everything such as coatings, upgrades and accessories
• hundreds of the latest frame styles to choose from plus latest lens and coating technology
• professional opticians to assist in selecting products
• offer applies to non-disposable contact lenses

To find a Bay Optical store near you, call the toll free store locator at 1-866-BAY-EYES. Or visit our web site at www.greenshield.ca

CLAIMING INFORMATION

• Present your Green Shield Identification Card as proof of being a Green Shield subscriber.
• The vision provider will apply the appropriate discount(s) to your claim and submit the claim directly to Green Shield for payment. You pay your vision provider any balance not covered under your vision benefit
• If no vision benefits exist, you pay your provider the full balance owing after the applicable discounts have been applied.

DENTAL

• Your deductible is $50 Single or $50 Family per benefit year (June 1 to May 31).
• Your overall Dental maximum is $1,000 per person, per benefit year (June 1 to May 31).
• Stated maximums are based on paid claims.
• Your co-insurance which is applied to the eligible allowed amount is 20% for Basic Services, 20% for Comprehensive Basic Services and 50% for Major Restorative services.
• Beginning on the date of the first paid claim, recalls are covered every 6 months, other exams and full mouth x-rays every 3 years.   
• Comprehensive Basic Services cover denture relines 1 every 3 years.
• Major Restorative Services cover standard dentures, crowns and bridges once every 5 years.
• Applicable lab, drug and other expenses are eligible to a maximum of 40% (50% cap on dentures) of the allowable professional fee. Any applicable co-payment is then applied.
• Your eligible claims are reimbursed at the level stated above and in accordance with the current Provincial Dental Association Fee Guide for General Practitioners. In provinces with more than one fee guide, Green Shield will reimburse according to the least expensive standard fee (or fee range).

BASIC SERVICES

• Recalls include exams, bitewing X-rays, preventive cleanings and fluoride treatments.
• Complete, general or comprehensive oral exams, full mouth x-rays and panoramic x-rays.
• Basic restorations, fillings and inlays.
• Extractions and surgical services. General anaesthetics and intravenous sedation only when done in conjunction with eligible extraction(s) and/or oral surgery. Sleep dentistry is not eligible.

COMPREHENSIVE BASIC SERVICES

• Endodontic treatment including standard root canal therapy, excluding retreatments.
• Periodontal treatment including scaling and/or root planing.
• Standard denture services including relining and rebasing of dentures plus denture adjustments after 3 months from installation

MAJOR RESTORATIVE SERVICES

• Standard dentures, complete, immediate and partial.
• Standard crown restorations or onlays on natural teeth.
• Repair or recementing of crowns, onlays and bridgework on natural teeth.
• Standard bridges, including pontics, abutment retainers/crowns on natural teeth.

TRAVEL BENEFITS

• Travel Benefits are eligible within the first 90 days per trip while traveling or vacationing outside of the Province/Country.
• Canadian residents are covered while temporarily residing outside of the country provided they maintain their government health insurance plan coverage.  Note:  the 90 day per trip out-of-province/country travel limit would apply.  
• Your maximum is $1,000,000 per calendar year for Emergency Services; and $50,000 per calendar year for Referral Services. 
• Hospital and medical services are eligible only if your provincial government health plan provides payment toward the cost of the services received.
• Green Shield must be contacted by phone within 48 hours of commencement of treatment, by dialing 1-800-936-6226 within Canada or USA or call collect 0 519-742-3556.  These telephone assistance numbers are also located on the reverse of your Green Shield Identification Card.
• Green Shield, through consultation with the Assistance Medical Team, reserves the right to repatriate the patient for treatment upon medical verification of the tolerance for travel.  Carry your Green Shield identification card with you when traveling.

For complete details on your travel benefits, please refer to the enclosed Deluxe Travel Plan Booklet.

Top of Page

MEMBER BENEFITS TRUST

CLASS – 5

OUTLINE OF BENEFITS

Services shown below will be eligible if they are usual, reasonable and customary, and are medically necessary for the treatment of an illness or injury.  Please contact the Member Benefits Trust at (604) 685-1678, or the Green Shield Customer Service Centre toll free at 1-888-711-1119 to determine benefit eligibility and coverage details.  Green Shield Canada’s Customer Service Centre is available 5:30 am to 4:30 pm Pacific Standard Time.

BENEFIT YEAR

• Your benefit year runs from June 1 to May 31 each year.  Where applicable, your deductible, co-pay and/or maximums will be calculated for this 12 month period each year.

DRUG

• A co-payment of 25% of the drug cost plus the dispensing fee applies to each prescription.
• Your overall Drug maximum is $5,000 per participant, per calendar year. 
• Drugs are eligible only if the drug is a benefit of your current provincial medical plan.
• Drugs may be submitted on a Pay Direct basis at your pharmacy.
• Benefits include drugs legally requiring a prescription by law, diabetic needles and syringes.   
• Benefits do not include medication for the treatment of anti-obesity, erectile dysfunction, and fertility.  Serums and vitamins are also ineligible unless injected and medically necessary.
• Smoking cessation products are covered with a $200 lifetime maximum per person. Products available over the counter are ineligible.
• If you are a resident of Ontario, The Ontario Drug Benefit co-pay for seniors is not a benefit.
• In the province of Quebec, legislation states that Green Shield Canada is obligated to follow RAMQ reimbursement guidelines for all residents of Quebec. For those 65 years of age and under, Green Shield Canada is primary payor.

HEALTH SERVICES

• Your overall Health deductible is Nil.
• Your co-payment for Health Services is 5%.
• Co-payments do not apply to Accommodations, Vision, Audio and Travel Benefits.
• Co-payments apply to Emergency Transportation, Medical Items, Paramedical Services, Dental Accident, and Eye Exams.

EMERGENCY TRANSPORTATION

• Ambulance Transportation, for land or air ambulance to the nearest hospital equipped to provide the required treatment.

ACCIDENTAL DENTAL BENEFITS

• Accidental Dental benefits for treatment by a dentist.  A dental accident report form must be submitted immediately following the accident.

ACCOMMODATION

SEMI-PRIVATE

• Semi-Private Room in a public general hospital   

AUDIO

• Reimbursement will be made for standard hearing aids, repairs or replacement parts up to a maximum of $750 once every 5 years.
• Batteries are not eligible.

MEDICAL ITEMS

Prosthetic Appliances and Durable Medical Equipment as well as replacements, repairs, fittings and adjustments of such devices.  Contact the Customer Service Centre to verify eligibility of a particular benefit.

OPTOMETRIST EYE EXAMS

• Optometrist eye examinations performed by a licensed Optometrist limited to one exam up to a maximum of $65 per 24 months.  Applicable co-payment will be applied.  Note:  the Provincial Health Care Plan must be used first (where applicable).

PARAMEDICAL SERVICES

• Physiotherapist, Registered Clinical Psychologist, Registered Clinical Counselor, Registered Social Worker, Chiropractor, Osteopath, Podiatrist/Chiropodist, Naturopath, Registered Massage Therapist (medical referral required), Speech Therapist, Acupuncturist (physician/surgeon or anyone licensed through the Acupuncture Foundation of Canada to perform acupuncture) up to a $500 maximum per paramedical discipline per benefit year (June 1 to May 31)

NOTE:

• The above listed paramedicals are subject to a combined overall maximum of $900, per participant, per benefit year (June 1 to May 31).
• All paramedical services, excluding Psychologist benefits, are subject to a maximum reimbursement of $50 per visit (June 1 to May 31). Applicable co-payment will apply.
• Paramedical services are only eligible when the practitioner rendering the service is licensed by their provincial association and that association is recognized by Green Shield Canada.  Please contact the Green Shield Customer Service Centre to confirm eligibility when in doubt.
• Private Duty Nursing Benefits carry a maximum of $15,000 per benefit year (June 1 to May 31) for the services of a registered nurse (R.N.) or registered nurses assistant (R.N.A.) in the home on a full or part shift basis.

VISION

• Your Vision Benefit carries a maximum of $250 every 24 months (or $250 every 12 months if a change in prescription occurs) for prescription eye glasses (including prescription sunglasses) and/or contact lenses and/or towards laser eye surgery provided they are dispensed by an Optometrist, an Optician or an Ophthalmologist.

Commencement of your benefit period is based on the initial date you receive vision benefits.  This service date is the actual pick-up date of the eyewear.

As a Green Shield subscriber, you have access to our national preferred provider vision network arrangement with “The Bay Optical” and “Zellers Vision Centre” stores.

All Green Shield subscribers are eligible to receive a discount of 33% off the regular prices available at “The Bay Optical” and “Zellers Vision Centres”. This offer applies to all extra coatings and upgrades. (Excludes disposable contact lenses).

Features of this great value-added service include:

• offer applies to any Green Shield subscriber, regardless of whether you have Green Shield vision benefits or not
• direct billing to Green Shield by the provider; the subscriber just pays any portion not covered
• trustworthy retail chains with convenient locations
• discount offer applies to everything such as coatings, upgrades and accessories
• hundreds of the latest frame styles to choose from plus latest lens and coating technology
• professional opticians to assist in selecting products
• offer applies to non-disposable contact lenses

To find a Bay Optical store near you, call the toll free store locator at 1-866-BAY-EYES. Or visit our web site at www.greenshield.ca

CLAIMING INFORMATION

• Present your Green Shield Identification Card as proof of being a Green Shield subscriber.
• The vision provider will apply the appropriate discount(s) to your claim and submit the claim directly to Green Shield for payment. You pay your vision provider any balance not covered under your vision benefit
• If no vision benefits exist, you pay your provider the full balance owing after the applicable discounts have been applied.

DENTAL

• Your deductible is nil.
• Your overall Dental maximum is $2,500 per person, per benefit year (June 1 to May 31), excluding Orthodontics.
• Your lifetime maximum for Orthodontic benefits is $1,000.
• Stated maximums are based on paid claims.
• Your reimbursement which is applied to the eligible allowed amount is 100% for Basic Services, 100% for Comprehensive Basic Services, 80% for Major Restorative Services and 50% for Orthodontics.
• Beginning on the date of the first paid claim, recalls are covered once every 6 months, other exams and full mouth x-rays every 3 years.
• Comprehensive Basic Services cover denture relines 1 every 3 years, based on the date of the first paid claim.
• Major Restorative Services cover standard dentures, crowns and bridges once every 5 years.
• Applicable lab, drug and other expenses are eligible to a maximum of 40% (50% cap on dentures) of the allowable professional fee. Any applicable co-payment is then applied.
• Your eligible claims are reimbursed at the level stated above and in accordance with the current Provincial Dental Association Fee Guide for General Practitioners. In provinces with more than one fee guide, Green Shield will reimburse according to the least expensive standard fee (or fee range).

BASIC SERVICES

• Recalls include exams, bitewing X-rays, preventive cleanings and fluoride treatments.
• Complete, general or comprehensive oral exams, full mouth x-rays and panoramic x-rays.
• Basic restorations, fillings and inlays.
• Extractions and surgical services. General anaesthetics and intravenous sedation only when done in conjunction with eligible extraction(s) and/or oral surgery. Sleep dentistry is not eligible.

COMPREHENSIVE BASIC SERVICES

• Endodontic treatment including standard root canal therapy, excluding retreatments.
• Periodontal treatment including scaling and/or root planing.
• Standard denture services including relining and rebasing of dentures plus denture adjustments after 3 months from installation

MAJOR RESTORATIVE SERVICES

• Standard dentures, complete, immediate and partial.
• Standard crown restorations or onlays on natural teeth.
• Repair or recementing of crowns, onlays and bridgework on natural teeth.
• Standard bridges, including pontics, abutment retainers/crowns on natural teeth.

ORTHODONTIC SERVICES

• Orthodontic treatment to straighten teeth and correct the bite.
• Subject to a usual and customary monthly cap as established by Green Shield.

TRAVEL BENEFITS

• Travel Benefits are eligible within the first 90 days per trip while traveling or vacationing outside of the Province/Country.
• Canadian residents are covered while temporarily residing outside of the country provided they maintain their government health insurance plan coverage.  Note:  the 90 day per trip out-of-province/country travel limit would apply.  
• Your maximum is $1,000,000 per calendar year for Emergency Services; and $50,000 per calendar year for Referral Services. 
• Hospital and medical services are eligible only if your provincial government health plan provides payment toward the cost of the services received.
• Green Shield must be contacted by phone within 48 hours of commencement of treatment, by dialing 1-800-936-6226 within Canada or USA or call collect 0 519-742-3556.  These telephone assistance numbers are also located on the reverse of your Green Shield Identification Card.
• Green Shield, through consultation with the Assistance Medical Team, reserves the right to repatriate the patient for treatment upon medical verification of the tolerance for travel.  Carry your Green Shield identification card with you when traveling.

For complete details on your travel benefits, please refer to the enclosed Deluxe Travel Plan Booklet.

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MEMBER BENEFITS TRUST

CLASS 6 AND 7

OUTLINE OF BENEFITS

Services shown below will be eligible if they are usual, reasonable and customary, and are medically necessary for the treatment of an illness or injury.  Please contact the Member Benefits Trust at (604) 685-1678, or the Green Shield Customer Service Centre toll free at 1-888-711-1119 to determine benefit eligibility and coverage details.  Green Shield Canada’s Customer Service Centre is available 5:30 am to 4:30 pm Pacific Standard Time.

BENEFIT YEAR

• Your benefit year runs from June 1 to May 31 each year.  Where applicable, your deductible, co-pay and/or maximums will be calculated for this 12 month period each year.

DRUG

• A co-payment of 5% of the drug cost plus the dispensing fee applies to each prescription.
• Your overall Drug maximum is $5,000 per participant, per calendar year. 
• Drugs are eligible only if the drug is a benefit of your current provincial medical plan.
• Drugs may be submitted on a Pay Direct basis at your pharmacy.
• Benefits include drugs legally requiring a prescription by law, diabetic needles and syringes.   
• Benefits do not include medication for the treatment of anti-obesity, erectile dysfunction, and fertility.  Serums and vitamins are also ineligible unless injected and medically necessary.
• Smoking cessation products are covered with a $200 lifetime maximum per person. Products available over the counter are ineligible.
• If you are a resident of Ontario, The Ontario Drug Benefit co-pay for seniors is not a benefit.
• In the province of Quebec, legislation states that Green Shield Canada is obligated to follow RAMQ reimbursement guidelines for all residents of Quebec. For those 65 years of age and under, Green Shield Canada is primary payor.

HEALTH SERVICES

• Your overall Health deductible is Nil.
• Your co-payment for Health Services is 5%.
• Co-payments do not apply to Accommodations, Vision, Audio and Travel Benefits.
• Co-payments apply to Emergency Transportation, Medical Items, Paramedical Services, Dental Accident, and Eye Exams.

EMERGENCY TRANSPORTATION

• Ambulance Transportation, for land or air ambulance to the nearest hospital equipped to provide the required treatment.

ACCIDENTAL DENTAL BENEFITS

• Accidental Dental benefits for treatment by a dentist.  A dental accident report form must be submitted immediately following the accident.

ACCOMMODATION

SEMI-PRIVATE

• Semi-Private Room in a public general hospital   

AUDIO

• Reimbursement will be made for standard hearing aids, repairs or replacement parts up to a maximum of $750 once every 5 years.
• Batteries are not eligible.

MEDICAL ITEMS

Prosthetic Appliances and Durable Medical Equipment as well as replacements, repairs, fittings and adjustments of such devices.  Contact the Customer Service Centre to verify eligibility of a particular benefit.

OPTOMETRIST EYE EXAMS

• Optometrist eye examinations performed by a licensed Optometrist limited to one exam up to a maximum of $65 per 24 months.  Applicable co-payment will be applied.  Note:  the Provincial Health Care Plan must be used first (where applicable).

PARAMEDICAL SERVICES

• Physiotherapist, Registered Clinical Psychologist, Registered Clinical Counselor, Registered Social Worker, Chiropractor, Osteopath, Podiatrist/Chiropodist, Naturopath, Registered Massage Therapist (medical referral required), Speech Therapist, Acupuncturist (physician/surgeon or anyone licensed through the Acupuncture Foundation of Canada to perform acupuncture) up to a $800 maximum per paramedical discipline per benefit year (June 1 to May 31)

NOTE:

• The above listed paramedicals are subject to a combined overall maximum of $2,000 per participant, per benefit year (June 1 to May 31).
• All paramedical services, excluding Psychologist benefits, are subject to a maximum reimbursement of $50 per visit (June 1 to May 31). Applicable co-payment will apply.
• Paramedical services are only eligible when the practitioner rendering the service is licensed by their provincial association and that association is recognized by Green Shield Canada.  Please contact the Green Shield Customer Service Centre to confirm eligibility when in doubt.
• Private Duty Nursing Benefits carry a maximum of $15,000 per benefit year (June 1 to May 31) for the services of a registered nurse (R.N.) or registered nurses assistant (R.N.A.) in the home on a full or part shift basis.

VISION

• Your Vision Benefit carries a maximum of $300 every 24 months (or $300 every 12 months if a change in prescription occurs) for prescription eye glasses (including prescription sunglasses) and/or contact lenses and/or towards laser eye surgery provided they are dispensed by an Optometrist, an Optician or an Ophthalmologist.

Commencement of your benefit period is based on the initial date you receive vision benefits.  This service date is the actual pick-up date of the eyewear.

As a Green Shield subscriber, you have access to our national preferred provider vision network arrangement with “The Bay Optical” and “Zellers Vision Centre” stores.

All Green Shield subscribers are eligible to receive a discount of 33% off the regular prices available at “The Bay Optical” and “Zellers Vision Centres”. This offer applies to all extra coatings and upgrades. (Excludes disposable contact lenses).

Features of this great value-added service include

• offer applies to any Green Shield subscriber, regardless of whether you have Green Shield vision benefits or not
• direct billing to Green Shield by the provider; the subscriber just pays any portion not covered
• trustworthy retail chains with convenient locations
• discount offer applies to everything such as coatings, upgrades and accessories
• hundreds of the latest frame styles to choose from plus latest lens and coating technology
• professional opticians to assist in selecting products
• offer applies to non-disposable contact lenses

To find a Bay Optical store near you, call the toll free store locator at 1-866-BAY-EYES. Or visit our web site at www.greenshield.ca

CLAIMING INFORMATION

• Present your Green Shield Identification Card as proof of being a Green Shield subscriber.
• The vision provider will apply the appropriate discount(s) to your claim and submit the claim directly to Green Shield for payment. You pay your vision provider any balance not covered under your vision benefit
• If no vision benefits exist, you pay your provider the full balance owing after the applicable discounts have been applied.

DENTAL

• Your deductible is nil.
• Your combined maximum for Basic and Comprehensive Basic Services is $2500.
• Your maximum for Major Restorative Services is $2,500 per person, per benefit year (June 1 to May 31).
• Your overall Dental maximum is $4,000 per person, per benefit year (June 1 to May 31), excluding Orthodontics.
• Your lifetime maximum for Orthodontic benefits is $2,500 per participant.
• Stated maximums are based on paid claims.
• Your reimbursement which is applied to the eligible allowed amount is 100% for Basic Services, 100% for Comprehensive Basic Services, 100% for Major Restorative Services and 50% for Orthodontics.
• Your maximum for teeth whitening is $600 every 2 years.
• Beginning on the date of the first paid claim, recalls are covered once every 6 months, other exams and full mouth x-rays once every 3 years.
• Comprehensive Basic Services cover denture relines 1 every 3 years, based on the date of the first paid claim.
• Major Restorative Services cover standard dentures, crowns and bridges once every 5 years.
• Applicable lab, drug and other expenses are eligible to a maximum of 40% (50% cap on dentures) of the allowable professional fee. Any applicable co-payment is then applied.
• Your eligible claims are reimbursed at the level stated above and in accordance with the current Provincial Dental Association Fee Guide for General Practitioners. In provinces with more than one fee guide, Green Shield will reimburse according to the least expensive standard fee (or fee range).

BASIC SERVICES

• Recalls include exams, bitewing X-rays, preventive cleanings and fluoride treatments.
• Complete, general or comprehensive oral exams, full mouth x-rays and panoramic x-rays.
• Basic restorations, fillings and inlays.
• Extractions and surgical services. General anaesthetics and intravenous sedation only when done in conjunction with eligible extraction(s) and/or oral surgery. Sleep dentistry is not eligible.

COMPREHENSIVE BASIC SERVICES

• Endodontic treatment including standard root canal therapy, excluding retreatments.
• Periodontal treatment including scaling and/or root planing.
• Standard denture services including relining and rebasing of dentures plus denture adjustments after 3 months from installation

MAJOR RESTORATIVE SERVICES

• Standard dentures, complete, immediate and partial.
• Standard crown restorations or onlays on natural teeth.
• Repair or recementing of crowns, onlays and bridgework on natural teeth.
• Standard bridges, including pontics, abutment retainers/crowns on natural teeth.

ORTHODONTIC SERVICES

• Orthodontic treatment to straighten teeth and correct the bite.
• Subject to a usual and customary monthly cap as established by Green Shield.

TRAVEL BENEFITS

• Travel Benefits are eligible within the first 90 days per trip while traveling or vacationing outside of the Province/Country.
• Canadian residents are covered while temporarily residing outside of the country provided they maintain their government health insurance plan coverage.  Note:  the 90 day per trip out-of-province/country travel limit would apply.  
• Your maximum is $1,000,000 per calendar year for Emergency Services; and $50,000 per calendar year for Referral Services. 
• Hospital and medical services are eligible only if your provincial government health plan provides payment toward the cost of the services received.
• Green Shield must be contacted by phone within 48 hours of commencement of treatment, by dialing 1-800-936-6226 within Canada or USA or call collect 0 519-742-3556.  These telephone assistance numbers are also located on the reverse of your Green Shield Identification Card.
• Green Shield, through consultation with the Assistance Medical Team, reserves the right to repatriate the patient for treatment upon medical verification of the tolerance for travel.  Carry your Green Shield identification card with you when traveling.

For complete details on your travel benefits, please refer to the enclosed Deluxe Travel Plan Booklet.

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