Healthcare Coverage

	LEVEL ONE	LEVEL TWO	LEVEL THREE
Prescription Drugs	50% on drugs	70% on drugs	80% on drugs
Covered Medications	Listing of eligible drugs (GreenShield formulary)
Out-of-Pocket Maximum	$2,500 per covered person, per plan year	$1,500 per covered person, per plan year	$1,000 per covered person, per plan year
Healthcare Spending (HSA)	$780 per plan year	$300 per plan year	$120 per plan year
Deductible	None
Coinsurance	50% Co-insurance on all covered health expenses, except emergency out of country.	70% Co-insurance on all covered health expenses except emergency out of country, vision, and hearing aids.	80% of Co-insurance on all covered health expenses, except emergency out of country vision, and health aids.
Overall Drug Maximum	$25,000 per individual per year	$45,000 per individual per year	$62,500 per individual per year
Hospital (Including Convalescent and Substance Abuse Treatment Facility)	No coverage	Semi-private	Semi-private
Nursing Care	No coverage	$5,000 to max 12 months per condition	$5,000 to max 12 months per condition
Psychologist (Paramedical)	No coverage	• 70% co-insurance • $1,000 per plan year	• 80% co-insurance • $1,500 per plan year
Chiropractor,Massage,and Physiotherapy (Paramedical)	No coverage	70% co-insurance $325 per plan year, per practitioner	80% co-insurance $425 per plan year, per practitioner
Other Paramedical	No coverage	70% co-insurance $250 per plan year, per practitioner (Acupuncturist, Audiologist, Chiropodist/ podiatrist, Dietitian, Naturopath, Occupational Therapist, Osteopath, Speech Therapist to a combined maximum of $500)	80% co-insurance $350 per plan year, per practitioner (Acupuncturist, Audiologist, Chiropodist/ podiatrist, Dietitian, Naturopath, Occupational Therapist, Osteopath, Speech Therapist to a combined maximum of $1,000)
Vision Care	No coverage	$225 per 24 months (12 months for dependent < 19)	$225 per 24 months (12 months for dependent < 19)
Eye Exams	No coverage	$75 per 24 months (12 months for dependent < 19)	$75 per 24 months (12 months for dependent < 19)
Orthopedic Shoes/ Orthotics	No coverage	Combined $400 per plan year	Combined $400 per plan year

LEVEL ONE

LEVEL TWO

LEVEL THREE

Prescription Drugs

50% on drugs

70% on drugs

80% on drugs

Covered Medications

Listing of eligible drugs (GreenShield formulary)

Out-of-Pocket Maximum

$2,500 per covered person, per plan year

$1,500 per covered person, per plan year

$1,000 per covered person, per plan year

Healthcare Spending (HSA)

$780 per plan year

$300 per plan year

$120 per plan year

Deductible

None

Coinsurance

50% Co-insurance on all
covered health expenses,
except emergency out of country.

70% Co-insurance on all
covered health expenses
except emergency out of country,
vision, and hearing aids.

80% of Co-insurance on all
covered health expenses,
except emergency out of country
vision, and health aids.

Overall Drug Maximum

$25,000 per individual per year

$45,000 per individual per year

$62,500 per individual per year

Hospital (Including Convalescent and Substance Abuse Treatment Facility)

No coverage

Semi-private

Nursing Care

No coverage

$5,000 to max
12 months per condition

$5,000 to max
12 months per condition

Psychologist (Paramedical)

No coverage

• 70% co-insurance

• $1,000 per plan year

• 80% co-insurance

• $1,500 per plan year

Chiropractor,Massage,and Physiotherapy (Paramedical)

No coverage

70% co-insurance
$325 per plan year, per practitioner

80% co-insurance
$425 per plan year, per practitioner

Other Paramedical

No coverage

70% co-insurance
$250 per plan year, per practitioner (Acupuncturist, Audiologist, Chiropodist/ podiatrist, Dietitian, Naturopath, Occupational

Therapist, Osteopath, Speech Therapist to a

combined maximum of $500)

80% co-insurance
$350 per plan year, per practitioner (Acupuncturist, Audiologist, Chiropodist/ podiatrist, Dietitian, Naturopath, Occupational

Therapist, Osteopath, Speech Therapist to a

combined maximum of $1,000)

Vision Care

No coverage

$225 per 24 months

(12 months for dependent < 19)

$225 per 24 months

(12 months for dependent < 19)

Eye Exams

No coverage

$75 per 24 months

(12 months for dependent < 19)

$75 per 24 months

(12 months for dependent < 19)

Orthopedic Shoes/ Orthotics

No coverage

Combined $400 per plan year

*OOP Out-of-Pocket (i.e. expenses not covered by insurance)

** Eligible mental health practitioners: Psychologist, Social Worker, Counselling Therapist, Psychoeducator, and Psychotherapist.

***Other Paramedical practitioners: Acupuncturist, Audiologist, Chiropodist / Podiatrist, Dietitian, Naturopath, Occupational Therapist, and Speech Therapist.

Healthcare Coverage

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