GENERAL INFORMATION
WELFARE PLAN
  BENEFIT HIGHLIGHTS
  ELIGIBLE DEPENDENTS
  DESCRIPTION OF BENEFITS
  LIFE INSURANCE
  ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
  WEEKLY INDEMNITY
  LONG TERM DISABILITY
  MAJOR MEDICAL BENEFITS
  DENTAL BENEFITS
  EMERGENCY OUT OF PROVINCE
  MEMBER AND FAMILY ASSISTANCE PLAN
  GENERAL EXCLUSIONS
  COORDINATION OF BENEFITS
  GENERAL INFORMATION
  PAY-DIRECT COVERAGE
  EXTENSION OF MAJOR MEDICAL AND DEATH BENEFITS ON AN EMPLOYEES' DEATH
  EXTENTION OF MAJOR MEDICAL AND DENTAL BEFEFITS IF SICK OR DIABLED
  NO BREAK IN SERVICE ARRANGEMENT
  DESIGNATION OF A BENEFICIARY
  BENEFITS PERTAINING TO PENSIONERS
  TERMINATED FORMER EMPLOYEES
  HOW TO SUBMIT CLAIMS
  TERMINATION OF WELFARE COVERAGE
  FUTURE OF THE PLAN
PENSION PLAN
MEMBER BENEFIT BOOKLET
 

 

WELFARE AND PENSION PLANS

Welfare Plan

DESCRIPTION OF BENEFITS


Major Medial Benefits (Employees and Dependents)

BOOKLET ADDENDUM

Effective December 1, 2014: Emergency Dental benefit is added to the Welfare Plan.

Eligible expenses for necessary dental treatment required as a result of an accidental injury to natural teeth provided the accident occurred while covered and subject to a maximum of $1,500 per calendar year per covered person.  As determined by the Plan Administrator, only such charges directly related to such an accidental injury are considered a covered health expense. The dental work must begin within 6 months of the accident and must be completed within 12 months of the accident to be considered a covered health expense (this limit is waived for dependent children, subject to receipt of a written report from the attending dentist outlining the treatment plan).

Note: Where there exists more than one customarily employed and professionally adequate method of treating the accidental injury to the teeth, the Plan Administrator reserves the right to determine eligible expenses on the basis of an alternate benefit, i.e. coverage is limited to the cost of the lowest priced alternate course of treatment.

Effective July 1, 2015: Hearing Aid coverage is changed from $1,500 Lifetime maximum to $1,500 every 5 years.

Effective March 1, 2016:Occupational Therapy is added as eligible paramedical expenses.
The benefit is subject to a maximum of $50 per treatment. There is no limit to the number of visits, but the benefit is subject to a maximum of $2,000 in a calendar year for all paramedical practitioners combined.

Chiropractor, Acupuncturist, Naturopath, Massage Therapist, Athletic Therapist, Occupational Therapist, Osteopath, Physiotherapist, Speech Therapist, Podiatrist or Chiropodist.
Physician's prescription is not required.

Major Medical Benefits (Employees and Dependents)

 

The specified Major Medical expenses are payable provided they are reasonable and customary, needed for medical care and provided they are not covered by your Provincial Medicare Plan up to an Overall Lifetime Maximum of $25,000 per covered person. When this maximum is reached, each covered person will be reimbursed up to a maximum of $5,000 per year thereafter. Note: these maximums do not apply to the Prescription Drug or Vision Care benefit.

The following expenses are covered at 100%, except as noted otherwise:

Prescription Drug Benefits

  • Reasonable and customary charges incurred for medically necessary drugs and medicines specified below.
  • Such drugs and medicines must be obtained only by prescription from a person entitled by law to prescribe them and dispensed by a licensed pharmacist, physician or other health care practitioner authorized by provincial legislation to dispense them.

No benefit shall be payable for any single purchase of drugs which would not reasonably be used within 90 days from the date of purchase.

  • Eligible Drug Expenses:
  • All generic drugs and life sustaining medications
  • Diabetic supplies such as needles, syringes, test strips, lancets and solutions
  • For retired members age 65 years and older, prescription drug costs in excess of that paid by a provincial drug plan, including any required annual premiums
  • Smoking cessation products will be reimbursed at 75% up to a maximum of $500 per calendar year
  • Erectile dysfunction drugs up to the maximum of $1,000 per calendar year
  • Oral contraceptives

 

  • Generic Drugs
  • If there is a generic substitute for the drug the covered person has been prescribed, the Welfare Plan will reimburse only up to the cost of the lowest priced generic equivalents regardless of whether the brand name or the generic equivalent is purchased.
  • If, for any reason, the covered person’s health care practitioner insists the covered person receive a certain brand name medication, the words “no substitution” must be included on the prescription.  The covered person will be reimbursed based on the cost of the brand name drug upon proof that the covered person’s health care practitioner has specified “no substitution.”
  • Ingredient Cost:

For drugs listed in the provincial Drug Benefit Formulary and Limited Use Drugs the ingredient cost will be limited to the current Formulary price plus a mark-up. For all other drugs the ingredient cost will be limited to the pricing followed by the major drug wholesaler in the applicable province, plus a mark-up.

  • Dispensing Fee:

There is a dispensing fee maximum eligible expense of $8.50 per prescription. Maintenance drugs are limited to one dispensing fee for each 90-day supply. Drug compounds, solutions, creams and mixtures will be reimbursed to a maximum of $30 for the professional fee. A drug compound is a special medication made from a mixture of drugs.

  • Prescription Drug Exclusions:
  • Over the counter medications or drugs for which a prescription is not required by law (federal or provincial)
  • Fertility drugs or drugs to promote abortion
  • Drugs which are not considered medically necessary, e.g. cosmetic or weight loss/lifestyle, unless they are approved under the Express Scripts Canada Prescription Drug Plan – Prior Authorization Procedure
  • Vitamins (injectable or oral) unless they legally require a prescription
  • Alcohol swabs
  • Medication which is provided and administered by a health care practitioner (unless they legally require a prescription)
  • Hospital Funded/Administered drugs are not covered by the Welfare Plan
  • HIV/AIDS medications
  • Contraceptive devices

 

Prior Authorization
  • Prior Authorization of medically prescribed drugs will be required for any drug that has multiple indications and/or new drugs entering the market after January 1, 2005. A prior authorization will be required to ensure that the drug is being administered for medical purposes only, prior to the payment of the drug.
  • Prior Authorization will also be required for new drugs entering the market by having the covered person’s health care practitioner confirm that this new more costly drug is necessary over the current medications being prescribed. The Prior Authorization will be needed before new drugs are paid for by the Welfare Plan.
Maintenance Drugs
  • These are drugs which you or your eligible dependent have been taking for at least 6 months and which you or your dependent are required to take for a long period of time for a particular condition.  Some examples of maintenance medications include blood pressure medication, heart medication, and thyroid pills.
  • Note:  The Welfare Plan will only cover one dispensing fee every 90 days for maintenance medication.

 

  • Important Note:  If You (Or Your Spouse) Are Age 65 or Over

For residents of all provinces, other than Nova Scotia, Newfoundland and Labrador: It is mandatory that you enrol in the provincial health plan for prescription drug coverage upon attaining age 65.  Any portion of a claim not covered by the covered person’s provincial plan may be paid through this Plan’s prescription drug benefits in conjunction with the Canadian Elevator Industry Welfare Plan rules.
In provinces where a premium payment is required to continue your provincial health plan coverage, the Canadian Elevator Industry Welfare Plan will reimburse you the cost of the provincial drug plan premium after you submit your paid receipt for reimbursement.
In Nova Scotia, Newfoundland and Labrador, a private plan is the first payor, so the Canadian Elevator Industry Welfare Plan will cover the eligible drug expenses. Any premium payment required to continue a covered person’s provincial health plan coverage will not be reimbursed under this Plan.

  • Charges for Standard Hospital accommodation (room and board only) for an unlimited period if not covered by a provincial health plan.
  • Charges for the following professional ambulance services for transportation to and from a Hospital for confinement:
  • Licensed ground ambulance service, when medically necessary, to transport the patient to the nearest hospital equipped to provide the required treatment
  • Emergency air ambulance service to the nearest hospital equipped to provide the required treatment when the physical condition of the patient prevents the use of another means of transportation, and, if the patient requires the services of a registered nurse during the flight, the services and return air fare for the registered nurse.
  • Charges for services provided upon the prescription of a Physician by a Convalescent Hospital to which the patient is transferred after confinement as a Hospital bed-patient for at least three days (but not for rehabilitation or custodial care).
  • Charges for the following services or supplies prescribed by a Physician unless provided by the hospital or other institution:
  • Oxygen and its administration.
  • Blood transfusions including the cost of the blood.
  • Services of registered graduate nurses, licensed practical nurses or registered nursing assistants (other than members of your family or the staff of the Hospital or Convalescent Hospital).

       Note: Nursing services provided in the Hospital are not covered.

  • Rental or purchase of wheelchairs or electric mobility scooters up to a combined $2,000 lifetime maximum.
  • Rental of hospital beds, iron lungs or intermittent positive-pressure breathing machines. (Individual consideration may be given by the Trustees to the purchase rather than rental of eligible equipment, as well as to the expenses incurred in its repair or adjustment.)
  • Splints, trusses, braces, orthopedic back supports, crutches, casts, artificial limbs and eyes and hair prosthesis.
  • Elastic support stockings purchased from a recognized surgical supply house up to a maximum of $100 in a calendar year. To be eligible, elastic support stockings must be recommended by a licensed doctor (M.D.) or podiatrist, provided the stockings have a compression value of at least 20 to 30 mmHg pressure and are required to treat a diagnosed medical condition as determined by the Plan Administrator.
  • Insulin infusion pump (one per lifetime), payable at 50% of the eligible expense.
  • Orthopedic shoes which are an integral part of a brace or which are specially constructed for the patient, any modifications to such shoes. Orthotics are also covered. Orthopedic shoes and orthotics are covered up to a total maximum of one pair in a calendar year.

To be covered under the plan, orthopedic shoes and orthotics must be recommended by a licensed doctor (M.D.), podiatrist or chiropodist, custom made and specifically designed and molded for the covered person, dispensed by a certified podiatrist, chiropodist, pedorthist or orthotist and required to correct a diagnosed physical impairment.
Recommendation must include the diagnosis, symptoms and chief complaints. No benefit will be provided if the orthopedic shoes or orthotics are prescribed or dispensed by a practitioner other than those listed above. To avoid misinterpretation of what is eligible and what may or may not qualify as a covered expense, you must submit an estimate to the Plan Administrator for confirmation prior to the purchase.

  • Hearing aids obtained on the written prescription of a Physician certified as an audiologist up to a $1,500 lifetime maximum.
  • Paramedical claims for reimbursement must be accompanied by a written prescription from the attending Physician and a letter from the Physician setting out the diagnosis of the condition which requires the services or supplies for the following items (i) and (ii).
    • Services of a registered clinical Psychologist up to a maximum of $50 per treatment, not to exceed 50 visits in a calendar year.
    • Services of the following paramedical practitioners up to a maximum of $50 per treatment.  There is no limit to the number of visits  but subject to a combined maximum of $2,500 for all paramedical practitioners in a calendar year:
  • a legally licensed and duly qualified Physiotherapist, a registered Massage Therapist or Athletic Therapist where all or a portion of such treatment is not covered by a government plan;
  • a duly qualified Speech Therapist
  • a legally licensed and duly qualified Chiropractor, Naturopath, Osteopath, or Chiropodist/Podiatrist.  Note: These benefits are only payable after the yearly maximum, if any, has been received from your Provincial Government Plan.  X-rays, medicines, drugs, or dressings ordered by one of the above are not covered under the Welfare Plan.
  • a duly registered Acupuncturist for the treatment of sickness or injury, where all or a portion of such treatment is not covered by your Provincial Government Plan.  Note: In no event shall acupuncture treatment be covered if used as a remedy for smoking, alcohol abuse, diet control or other addiction problems.  Physician’s prescription is not required.
  • With approval of the Trustees, reasonable charges for the services provided by a Home Health Agency under the care and direction of a Physician on a visiting basis in the patient’s home, unless coverage is available under a provincial medical plan.

Note:

Homemaker services are not covered.


  • Vision Care –
    • Purchase, repair or replacement of lenses and frames for eyeglasses or contact lenses, or laser eye surgery, prescribed by a Physician or Optometrist up to a maximum of $400 every two calendar years.  Eyeglasses purchased (or repaired) for dependent children under age 14 at the date of purchase will be payable up to a maximum of $400 each calendar year.
    • In addition, if visual acuity of 20/40 cannot be achieved by eyeglasses and this is confirmed in writing by your Physician or Optometrist, a maximum of $550 is payable during the fifth calendar year following the year in which the last purchase was made towards the purchase of contact lenses prescribed by a Physician or Optometrist for severe corneal astigmatism or scarring. 

If written confirmation cannot be obtained from your Physician or Optometrist, your contact lenses will be covered in accordance with the coverage for eyeglasses in (a) above.

Charges for eye examinations, if not covered by a provincial health plan, up to a maximum of $90 every 2 calendar years.


 

   

READ CAREFULLY, BUT REMEMBER…

This is a general outline of the Plans and its purpose is to explain as briefly and clearly as possible each of the benefits to which you are entitled. The benefits outlined under the Plans are subject to the terms and conditions of the Plan documents and Group Master Policies. If there is any conflict between this outline and the Plan documents and Group Master Policies, the Plan documents and Group Master Policies will apply in all cases. Also remember that no benefits are guaranteed and that the benefits can be changed by the Trustees at any time.

 
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