325156 b1 active and retired post 6.6.00 · You should know 325156-B1 (2008-02-01.version32) 1 YOU...

WARNING :

© The Great‐West Life Assurance Company. This version of the contract is sent to you for convenience of reference only. Please refer to the most current paper version of this document. In the event of any discrepancy between the attached version(s) and the most current paper version(s), the provisions of the most current paper version(s) will govern. This file is write‐protected. No additions, deletions, or modifications may be made to this file without the express written permission of Great‐West Life.

Exhibit No. 325156-B1

UNIVERSITY OF WATERLOO

Includes all eligible active and retired employees (post June 6, 2000)

PROTECTING YOUR PERSONAL INFORMATION

At Great-West Life, we recognize and respect the importance of privacy. Personal information about you is kept in a confidential file at the offices of Great-West Life or the offices of an organization authorized by Great-West Life. Great-West Life may use service providers located within or outside Canada. We limit access to personal information in your file to Great-West Life staff or persons authorized by Great-West Life who require it to perform their duties, to persons to whom you have granted access, and to persons authorized by law. Your personal information may be subject to disclosure to those authorized under applicable law within or outside Canada.

We use the information to administer the group benefit plan under which you are covered. This includes many tasks, such as:

determining your eligibility for coverage under the plan enrolling you for coverage investigating and assessing your claims and providing you with payment managing your claims verifying and auditing eligibility and claims creating and maintaining records concerning our relationship underwriting activities, such as determining the cost of the plan, and analyzing the

design options of the plan preparing regulatory reports, such as tax slips

Your employer has an agreement with Great-West Life in which your employer has financial responsibility for some or all of the benefits in the plan and we process claims on your employer’s behalf. We may exchange personal information with your health care providers, your plan administrator, any insurance or reinsurance companies, administrators of government benefits or other benefit programs, other organizations, or service providers working with us or the above when relevant and necessary to administer the plan.

As plan member, you are responsible for the claims submitted. We may exchange personal information with you or a person acting on your behalf when relevant and necessary to confirm coverage and to manage the claims submitted.

You may request access or correction of the personal information in your file. A request for access or correction should be made in writing and may be sent to any of Great-West Life’s offices or to our head office.

For a copy of our Privacy Guidelines, or if you have questions about our personal information policies and practices (including with respect to service providers), write to Great-West Life’s Chief Compliance Officer or refer to www.greatwestlife.com.

325156-B1 (2008-02-01.version32)

GROUP BENEFIT PLAN

Table of Contents

YOU SHOULD KNOW .................................................................................................. 1

DEFINITIONS ............................................................................................................... 2

WHO IS ELIGIBLE TO BECOME COVERED ............................................................... 4

EFFECTIVE DATE OF COVERAGE ............................................................................. 6

TERMINATION OF COVERAGE .................................................................................. 8

WHEN YOU HAVE A CLAIM ...................................................................................... 10

GENERAL INFORMATION ......................................................................................... 12

PART I. INSURED COVERAGES .................................................................................... 15

SUMMARY OF COVERAGES .................................................................................... 16

LONG TERM DISABILITY COVERAGE ..................................................................... 18

GLOBAL MEDICAL ASSISTANCE COVERAGE ........................................................ 27

PART II. ASO COVERAGES ........................................................................................... 31

SUMMARY OF COVERAGES .................................................................................... 32

PAY-DIRECT PRESCRIPTION DRUG PLAN ............................................................. 35

EXTENDED HEALTH CARE COVERAGE ................................................................. 39

DENTAL CARE COVERAGE ...................................................................................... 47

PART III. PREFERRED VISION SERVICES (PVS) ......................................................... 57

You should know

325156-B1 (2008-02-01.version32) 1

YOU SHOULD KNOW

Effective Date of Plan - January 1, 1996

Effective Date of Revised Plan - November 1, 2008

Covered Classes - All eligible active and retired employees (post June 6, 2000)

IMPORTANT

The Long Term Disability Coverage and Global Medical Assistance Coverage described in Part I of this group benefit plan are insured under Group Policy No. 325156 issued to the Contractholder by Great-West Life.

The Pay-Direct Prescription Drug Plan, Extended Health Care Coverage and Dental Care Coverage described in Part II of this group Benefit plan are not insured but are administered on behalf of the Contractholder by Great-West life pursuant to Administrative Services Agreement (ASO) No. 57130 between the Contractholder and Great-West Life. Because these coverages are not insured, they are not protected by Assuris.

Preferred Vision Services (PVS) described in Part III of this group benefit plan is a service provided by Great-West Life to its customers through Preferred Vision Services. It does not form part of the contract issued to the Contractholder by Great-West Life.

The coverages are available to you if you are included in the covered classes shown above. Only those coverages for which you become covered will apply to you.

Conformity with law

If any provision of this group benefit plan conflicts with any law which applies to individuals shown in the covered classes, the plan will be amended to conform to that law.

Cost

The employer pays the entire cost of the coverage for employees who work on a full-time basis. Employees who work on a part-time basis pay a pro-rated premium.

Waiting period

There is no waiting period. You are eligible for coverage on your first day of full-time or part-time employment.

The coverages are described in full on later pages. Be sure to read these pages carefully. They show when benefits are or are not payable, and outline the conditions, limitations and exclusions that apply to the coverages.

Definitions

325156-B1 (2008-02-01.version32) 2

DEFINITIONS

Unless specifically stated otherwise, the following definitions apply throughout this group benefit plan.

ACTIVELY AT WORK means you are working at your usual place of employment and performing all of the usual and customary duties of your occupation on a regular full-time or part-time basis.

BENEFITS means any amounts which become payable under a coverage.

CALENDAR YEAR means January 1 through December 31.

CONTRACT means, as the case may be:

(1) Group Insurance Policy No. 325156 which provides Long Term Disability Coverage and Global Medical Assistance Coverage; or

(2) Administrative Services Agreement No. 57130 which applies to the Pay-Direct Prescription Drug Plan, Extended Health Care Coverage and Dental Care Coverage.

CONTRACTHOLDER means, as the case may be:

(1) University of Waterloo in its capacity as the Policyholder of Group Insurance Policy No. 325156, which provides Long Term Disability Coverage and Global Medical Assistance Coverage; or

(2) University of Waterloo in its capacity as the Purchaser of Administrative Services Agreement No. 57130, which applies to the Pay-Direct Prescription Drug Plan, Extended Health Care Coverage and Dental Care Coverage.

COVERED PERCENTAGE is the percentage of eligible charges shown in the Summary of Coverages, which will be reimbursed under a coverage.

COVERED PERSON is an individual who is covered for employee coverage under a coverage, or a qualified dependent with respect to whom an employee is covered for dependents coverage under a coverage.

EARNINGS means your annual salary paid by the employer, as reported for premium purposes, up to a maximum of $150,000, less deductions for federal and provincial income taxes based on the income tax status used for payroll purposes, Canada and Quebec Pension Plan contributions, federal Employment Insurance premiums and normal University of Waterloo pension plan contributions.

EMPLOYER means University of Waterloo.

FULL-TIME BASIS means you regularly work for the employer:

(1) at least 35 hours per week for non-union employees; or

(2) at least 40 hours per week for union employees.

GREAT-WEST LIFE means The Great-West Life Assurance Company.

PART-TIME BASIS is as determined by the employer.

PHYSICIAN means a duly licensed doctor of medicine (M.D.).

Definitions

325156-B1 (2008-02-01.version32) 3

PROVINCE or PROVINCIAL refers to any province or territory of Canada.

SICKNESS means any disorder of the body or mind, including one caused by pregnancy.

YOU refers to the employee of the employer as shown in the covered classes on the You Should Know page. You are a covered person working on a regular full-time or part-time basis or on a reduced workload appointment, working 50% of full-time or more, including full-time term appointments of one year or more, or you are retired.

Who is eligible to become covered

325156-B1 (2008-02-01.version32) 4

WHO IS ELIGIBLE TO BECOME COVERED

FOR EMPLOYEE COVERAGE

You are eligible for employee coverage when you:

(1) are within the covered classes shown on the You Should Know page;

(2) are working on a full-time or part-time basis; and

(3) have completed the waiting period shown on the You Should Know page.

If your coverage ends because of leave of absence, layoff or disability and you are re-employed within 6 months of the date of termination, you will be eligible for coverage on the first day you are actively at work.

FOR DEPENDENTS COVERAGE

You are eligible for dependents coverage while you are eligible for employee coverage and you have a qualified dependent.

"Qualified dependent" means your spouse and dependent children as defined below.

SPOUSE

“Spouse” means either:

(1) an individual to whom you are legally married; or

(2) your common-law spouse who is an individual of either sex with whom you have been cohabiting for a period of at least 12 months and whom you publicly represent as your spouse.

You must state the name of the person to be considered your spouse for the purposes of the contract. Only one spouse will be considered at any time as being covered under the contract.

Who is eligible to become covered

325156-B1 (2008-02-01.version32) 5

DEPENDENT CHILD

"Dependent child" means an unmarried person who is:

(1) your natural child or your adopted child; or

(2) a step-child, child of a common-law spouse (of whom the spouse has legal custody), or child for whom you have been appointed legal guardian by a court of competent jurisdiction, who resides with you .

Such child must be:

(1) dependent on you for support;

(2) not employed on a full-time basis (not working more than 30 hours per week);

(3) younger than 21 years of age; or

(4) if a full-time student at an accredited school, college or university, under 23 years of age; or

(5) incapable of self-sustaining employment due to a mental or physical handicap provided the child was covered under the contract as a dependent and remains dependent on you for support.

Any individual residing outside of Canada will not be eligible to be covered, unless an exception is requested by the employer and approved in writing by Great-West Life.

If you and your spouse are employed by the employer, each of you may be eligible for and apply for employee coverage subject to the following limitations:

(1) only one employee can be covered for dependents coverage; and

(2) an individual covered as an employee cannot also be covered as a dependent.

Effective date of coverage

325156-B1 (2008-02-01.version32) 6

EFFECTIVE DATE OF COVERAGE

EMPLOYEE COVERAGE

The effective date of your coverage will be determined as follows:

(1) When you are required to contribute toward the cost of coverage, on the later of the following dates:

(a) the date you become eligible for employee coverage;

(b) the date your completed written application is received by the employer, provided application is made within 31 days of your date of eligibility. However, if you apply later than 31 days after your date of eligibility, you must provide evidence of insurability and the effective date of your coverage will be the date Great-West Life approves the evidence.

(2) When you are not required to contribute toward the cost of coverage, your coverage will commence on your date of eligibility.

(3) When your coverage exceeds the no evidence limit shown in the Summary of Coverages, the excess coverage will be effective on the date Great-West Life approves the evidence of insurability.

If you are covered under your spouse's health care plan and you are a part-time employee, you may choose not to become covered for the extended health care coverage under this group benefit plan. However, if coverage under your spouse's plan should terminate, you may apply for the extended health care coverage under this group benefit plan within 31 days. Should you apply after the 31-day period, you must provide evidence of insurability and the effective date of your coverage will be the date Great-West Life approves the evidence.

Evidence of insurability may be required to be submitted at your expense.

In any event, if you are not actively at work on the date your coverage is to be effective, it will become effective when you return to active work.

DEPENDENTS COVERAGE

The effective date of a dependent's coverage will be the latest of the following dates:

(1) If you already have a qualified dependent at the time you become eligible for employee coverage, that dependent's coverage will be effective on the date the employee coverage is effective. However, if you applied later than 31 days after the effective date of your own coverage, evidence of insurability must also be submitted for each of your dependents and their coverage will be effective on the date Great-West Life approves the evidence.

(2) If you have dependents coverage on a dependent on the date you acquire another qualified dependent, this dependent's coverage will be effective immediately.

Effective date of coverage

325156-B1 (2008-02-01.version32) 7

(3) If you have no qualified dependents at the time you become eligible for employee coverage and later acquire a qualified dependent, this dependent's coverage will be effective on the date you apply for dependents coverage, provided application is made within 31 days of the date you are first eligible for dependents coverage, otherwise the dependent's coverage will be effective on the date Great-West Life approves the evidence of insurability submitted for the dependents.

(4) A dependent's coverage will be effective on the date the dependent is discharged from the hospital if the dependent, other than a newborn child, is confined in a hospital on the date his or her coverage would otherwise have commenced.

Evidence of a dependent's insurability may be required to be submitted at your expense.

CHANGE IN COVERAGE

If your coverage changes due to a change in earnings or classification, or as a result of a plan change, your coverage will not be adjusted until the first day, on or after the date of the change, on which you are actively at work and the appropriate contribution is being made.

If your dependents coverage changes due to a change in your classification, or as a result of a plan change, and a dependent (other than a newborn child) is confined in a hospital on the effective date of the change, the coverage will not be adjusted until the dependent is discharged from the hospital.

Termination of coverage

325156-B1 (2008-02-01.version32) 8

TERMINATION OF COVERAGE

EMPLOYEE COVERAGE

Your coverage will terminate on the earliest of the following dates:

(1) the date you cease to be a member of any eligible class because of termination of employment (described below) with the employer or for any other reason;

(2) the date your class is terminated;

(3) the date you enter service in the armed forces of any country;

(4) the date the employer ceases to make contributions for you;

(5) the date you attain the termination age shown in the Summary of Coverages; and

(6) the date the contract terminates.

Termination of employment

For the purposes of the contract, your employment will be considered to terminate when you are no longer actively at work for the employer. However, if you are absent from work for any of the reasons described in the Continuation of Coverage During Absence From Work section below, the employer may, without discrimination among persons in like circumstance, consider you as not having terminated employment for the purposes of the contract and as continuing to be a member of any eligible class, and coverage will then be continued as outlined in the section below.

CONTINUATION OF COVERAGE DURING ABSENCE FROM WORK

Your coverage will be continued while you are absent from work due to sickness or injury, temporary layoff or approved leave of absence, or retirement, until the earliest of the dates specified in the above Employee Coverage section. If you are on a sabbatical, your Extended Health Care Coverage will be continued if you have O.H.I.P. coverage, and the above conditions have been met.

If the employer has terminated your employment and is required to extend benefits to you during a prescribed notice of termination in accordance with any federal or provincial employment standards legislation, you may continue to be covered under the contract for that period. The employer must ask for the continuation in writing and in no event will it extend past the date on which the contract terminates.

Termination of coverage

325156-B1 (2008-02-01.version32) 9

DEPENDENTS COVERAGE

A dependent's coverage will terminate on the earliest of the following dates:

(1) the date your own coverage terminates;

(2) the date the dependent ceases to be a qualified dependent;

(3) the date Great-West Life receives a request to terminate the dependent's coverage; and

(4) the date the employer ceases to make contributions for dependents coverage.

When you have a claim

325156-B1 (2008-02-01.version32) 10

WHEN YOU HAVE A CLAIM

LONG TERM DISABILITY COVERAGE

Contact the employer to obtain the proper claim forms and instructions. Forms should be completed without delay to ensure prompt payment of your benefits.

SUBMISSION OF HEALTH AND DENTAL CLAIMS

To make a health claim

Out-of-country claims (other than those for global medical assistance expenses) should be submitted to Great-West Life as soon as possible after the expense is incurred. It is very important that you send your claims to the Great-West Life Out-of-Country Claims Department immediately as your provincial medical plan has very strict time limitations.

Obtain the Statement of Claim Out-of-Country Expenses form from your employer. Unless you are a resident of the Territories you must also obtain the Government Assignment form, and residents of British Columbia, Quebec and Newfoundland & Labrador must also obtain the Special Government Claim form. The Great-West Life Out-of-Country Claims Department will forward the appropriate government forms to your attention when required.

If you are a resident of the Territories, you must submit your out-of-country claims to your territorial government for processing before submitting the claim to Great-West Life. When you receive your Explanation of Benefits back from the territory, please send the following to the Great-West Life Out-of-Country Claims Department (be sure to keep copies for your own records):

(1) a copy of the payment from your territory.

(2) a completed Statement of Claim Out-of-Country Expenses form.

(3) all required information.

(4) copies of all original receipts.

Residents of the provinces should complete all applicable forms, making sure all required information is included. Attach all original receipts and forward the claim to the Great-West Life Out-of-Country Claims Department. Be sure to keep a copy for your own records. The plan will pay all eligible claims including your provincial medical plan portion. Your provincial medical plan will then reimburse the plan for the government’s share of the expenses.

Out-of-country claims must be submitted within a certain time period that varies by province. For the claims submission period applicable in your province or territory or for any other questions or for assistance in completing any of the forms, please contact Great-West Life’s Out-of-Country Claims Department at 1-800-957-9777.

When you have a claim

325156-B1 (2008-02-01.version32) 11

For all other health claims, obtain the health claim form from the employer and send the completed form directly to Great-West Life.

(1) Keep a separate running record of the covered expenses for each covered person.

(2) Save all bills; in most instances they will serve as proof of claim.

(3) Submit claims when a reasonable number of bills and receipts have been accumulated.

(4) Avoid frequent submission of small claims, but large claims should be submitted promptly.

(5) Each claim, other than for drugs, should include:

(a) patient's full name,

(b) date or dates the service was rendered or purchase was made,

(c) nature of the sickness or injury,

(d) type of service or supply furnished,

(e) itemized charges, and

(f) attending physician's written referral or prescription. (This is not required when the service or supply is furnished by a physician. Physician is as defined in the Extended Health Care Coverage.)

(6) Each drug bill must show:

(a) patient's full name,

(b) prescription number and name of medication, and

(c) date of purchase and the charge for each item.

Also refer to the procedures for using the pay-direct prescription drug plan as described on later pages of this group benefit plan.

Submit only original bills and receipts; photocopies or carbon copies are not acceptable.

To make a dental claim

Obtain the dental claim form from the employer, complete the claimant's portion and have the dental service provider complete the attending provider’s statement. The form should then be sent directly to Great-West Life.

General information

325156-B1 (2008-02-01.version32) 12

GENERAL INFORMATION

CLAIM RULES

Proof of loss

The time limits for submitting proof of loss under a coverage are described in the applicable coverage description page.

Failure to furnish any such proof within the time required will not invalidate or reduce any such claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible.

Physical examination

Great-West Life, at its own expense, will have the right and opportunity to have any covered person, whose injury, sickness or treatment is the basis of a claim, examined by a physician or dentist designated by Great-West Life when and as often as it may reasonably require during the period of a claim under the contract.

Legal action

No action at law or in equity will be brought to recover under the contract prior to the expiration of 60 days after written proof of loss has been furnished in accordance with requirements of the contract.

OVERPAYMENT OF BENEFITS

Nothing in this group benefit plan will prevent Great-West Life from recovering any overpayment of benefits from the person or organization to whom such payment has been made, irrespective of the cause of such overpayment.

COORDINATING COVERAGE GUIDELINES FOR OUT-OF-COUNTRY/PROVINCE HEALTH CARE EXPENSES

If a person who is covered under the contract for global medical assistance coverage or for expenses resulting from emergency or referral health care provided outside Canada or outside the province of residence under the extended health care coverage is also covered under another plan or plans* which provides similar coverage, any claim will be coordinated with the other plan(s) in accordance with the coordinating coverage guidelines for out-of-country/province health care expenses as outlined by the Canadian Life and Health Insurance Association Inc.

* The "other plans" may include employment-related group contracts, individual or group travel or health policies, credit card coverages or any other private insurance source.

General information

325156-B1 (2008-02-01.version32) 13

COORDINATION OF BENEFITS

If a person who is covered under the contract for extended health care coverage is also covered under another plan* which provides similar coverage, any claim will be coordinated and/or reduced so that benefits payable from all plans will not exceed 100% of the eligible charges incurred.

* The "other plan" is defined as group insurance or any other arrangement of coverage for individuals in a group, whether on an insured or uninsured basis, including any prepayment coverage or capitation plan, as long as the group is not formed solely for the purpose of obtaining insurance. This definition of other plan does not include school insurance or individual travel insurance.

If a person is eligible to receive benefits under this plan and the same, or similar benefits under another plan, payment will be determined as follows:

(1) The plan which does not contain a coordination of benefits provision will pay before the plan which does.

(2) If the other plan(s) contains a coordination of benefits provision, priority will be given to the plan(s) in the following order:

(a) The plan where the person is covered as a member. However, if a person is a member of 2 or more plans, priority will be given as follows:

(i) the plan where the member is covered as an active full-time employee,

(ii) the plan where the member is covered as an active part-time employee,

(iii) the plan where the member is covered as a retiree.

(b) The plan where the person is covered as a dependent spouse.

(c) The plan where the person is covered as a dependent child. However, if a person is covered as a dependent child under 2 or more plans, priority will be given as follows:

(i) the plan of the parent with the earlier date of birth (month/day) in the calendar year,

(ii) the plan of the parent whose first name begins with the earlier letter in the alphabet, if the parents have the same date of birth.

An exception to this rule occurs if the parents are separated/divorced, in which case priority will be given as follows:

(i) the plan of the parent with custody of the child,

(ii) the plan of the spouse of the parent with custody of the child,

(iii) the plan of the parent not having custody of the child,

(iv) the plan of the spouse of the parent in (iii) above.

(d) Health plans with dental accident coverage will determine benefits before dental plans, where a person may be able to claim under both plans.

(e) If priority cannot be established using the above priorities, the benefits will be prorated in proportion to the amounts that would have been paid under each plan had there been coverage under just that plan.

General information

325156-B1 (2008-02-01.version32) 14

If payments which should have been made under the contract by the terms of this coordination of benefits provision have been made under any other plan, Great-West Life will have the right to pay to any company or organization the amount necessary to satisfy the intent of this Coordination of Benefits provision. The amounts paid in this manner will be considered benefits paid under the contract and Great-West Life will be fully discharged from liability to the extent of the payments made.

If payments have been made by Great-West Life under the contract which are in excess of the maximum amount of payment necessary to satisfy the intent of this Coordination of Benefits clause, Great-West Life will have the right to recover any such excess from any company or organization or person to or for whom such payments were made.

TO WHOM PAYABLE

Benefits under a coverage will be payable to you unless otherwise specified within the coverage.

Part I. Insured coverages

325156-B1 (2008-02-01.version32) 15

PART I. INSURED COVERAGES

The Long Term Disability Coverage and Global Medical Assistance Coverage described in this part of the group benefit plan are insured under Group Policy No. 325156 issued to the Contractholder by Great-West Life.

Summary of coverages

325156-B1 (2008-02-01.version32) 16

SUMMARY OF COVERAGES

COVERAGES FOR YOU


(Applicable to Faculty, Non-Union Staff, Union Bi-Weekly, Church College and Centre and Affiliate with Full Benefits)

Basic monthly benefit: An amount equal to 85% of your monthly take-home pay, up to a maximum of $10,000. All monthly benefits that are not even dollar amounts are rounded to the next higher dollar.

For non-taxable plans, the monthly benefit is the lesser of the above amount and the all source maximum.

Optional monthly benefit: Employees with annual earnings in excess of $150,000 may purchase an additional monthly benefit amount equal to 85% of your total monthly take-home pay less the basic monthly benefit amount. All monthly benefits that are not even dollar amounts are rounded to the next higher dollar.

To become covered for the optional monthly benefit, you will be required to submit evidence of insurability satisfactory to Great-West Life.

Waiting period as follows:

(1) For Faculty with Full Benefits: Benefits are payable after a waiting period of 180 days.

(2) For Non-Union Staff, Union Bi-Weekly, Church College and Centre and Affiliate with Full Benefits: Benefits are payable after a waiting period 90 days or the expiration of sick leave benefits to a maximum of 180 days.

Initial assessment period: The initial assessment period is the waiting period plus the next 24 months of disability. During this period, your disability is assessed on the basis of the duties you regularly performed for the employer before disability started.

All source maximum: The all source maximum is 85% of your take-home pay. The all source maximum is used in calculating the monthly benefit for non-taxable plans and in calculating the amount payable in connection with other sources of income for both taxable and non-taxable plans. This is explained later in the Long Term Disability Coverage description pages.

Cost-of-living adjustment: On the May 1st payment following the start of the benefit period and annually after that, your amount of disability benefit will be adjusted by the cost-of-living adjustment shown in the Long Term Disability Coverage description pages. During the first year of your disability, the cost-of-living adjustment may be pro-rated. In no event will your benefit be reduced as a result of the cost-of-living adjustment.

Summary of coverages

325156-B1 (2008-02-01.version32) 17

Benefit period: Benefits are payable up to your 65th birthday.

Tax status: Since you pay the entire cost of this coverage, your long term disability benefits are non-taxable.

Termination: At the end of the month in which you attainment age 65 or your retirement, if earlier.

COVERAGES FOR YOU AND YOUR QUALIFIED DEPENDENTS

GLOBAL MEDICAL ASSISTANCE COVERAGE

This coverage is described in detail on later pages.

Long term disability coverage

325156-B1 (2008-02-01.version32) 18


FOR YOU

A. ASSESSMENT RESPONSIBILITY

Great-West Life has full responsibility for the assessment of your entitlement to benefits.

B. DISABILITY

Long term disability income benefits under the contract are for disability periods that start while you are covered.

During the initial assessment period:

During the initial assessment period shown in the Summary of Coverages, you are considered disabled if:

(1) disease or injury prevents you from performing the essential duties of your regular occupation; and

(2) except for any employment under an approved rehabilitation plan, you are not employed in any occupation that is providing you with income equal to or greater than the monthly benefit available under this plan, as shown in the Summary of Coverages.

After the initial assessment period:

After the initial assessment period, you are considered disabled if disease or injury prevents you from being gainfully employed.

"Gainful employment" means work:

(1) you are medically able to perform;

(2) for which you have at least the minimum qualifications;

(3) that provides income of at least 60% of your pre-disability take-home pay; and

(4) that exists either in the province or territory where you worked when you became disabled or where you currently live.

The availability of work will not be considered in assessing disability.

Loss of License:

Loss of any license required for work will not be considered in assessing disability.


325156-B1 (2008-02-01.version32) 19

C. DISABILITY PERIOD

A disability period is:

(1) the waiting period; plus

(2) the benefit period.

D. WAITING PERIOD

The waiting period starts when you first become disabled and lasts, if disability is continuous, for the number of days shown in the Summary of Coverages.

If disability is not continuous, the days you are disabled will be accumulated to satisfy the waiting period as long as:

(1) no interruption is longer than 8 weeks; and

(2) the disabilities arise from the same disease or injury.

E. BENEFIT PERIOD

A benefit period is:

(1) the period of time after the waiting period during which you are continuously disabled; plus

(2) if the disability is not continuous, any period of time during which the disability is considered to be a recurrence.

A benefit period will not continue past your 65th birthday.

F. RECURRENCE

After the waiting period, a disability is considered a recurrence if it arises from the same disease or injury and starts:

(1) within 6 months after the previous disability ends; or

(2) within 6 months after the end of an approved rehabilitation plan.

G. INCOME BENEFITS

You are entitled to income benefits after the waiting period ends and for as long as the benefit period lasts. No income benefits are payable for the waiting period itself.

Amount payable:

The amount payable is the monthly benefit shown in the Summary of Coverages in effect at the start of the disability period, less the reductions, if any, required under the offset and all source maximum provisions. The monthly benefit is payable to you monthly in arrears. One thirtieth of the monthly benefit is payable for each day of any period less than a full month.


325156-B1 (2008-02-01.version32) 20

At Great-West Life’s discretion, the monthly benefit may be paid more frequently than monthly, on a pro-rated basis.

The income used in the offset and all source maximum provisions is the income payable for the same period as the monthly benefit under the contract.

Except for retirement benefits, all income is considered payable when you are entitled to it, whether or not it has been awarded or received. If it has not been awarded, Great-West Life will have the right to estimate it according to the terms of any plans or legislation involved. Retirement benefits are considered payable when they are actually received.

If income is payable in a lump sum, the amount used will be the portion payable for loss of income during the benefit period.

Before the amount payable is calculated under a non-taxable plan, taxable income will be reduced by the deductions specified under this plan’s take-home pay definition. This does not apply to Canada Pension Plan or Quebec Pension Plan benefits or to benefits from a similar plan in another country which has a reciprocal agreement with Canada or Quebec.

"Take-home pay" means your monthly earnings in effect immediately prior to the end of the waiting period on which premium is paid, to a maximum of $12,500, less deductions for federal and provincial income taxes based on the income tax status used for payroll purposes, Canada and Quebec Pension Plan contributions, federal Employment Insurance premiums and normal University of Waterloo pension plan contributions.

Offset provision:

Under this provision, your monthly benefit is reduced by the following income:

(1) Disability or retirement benefits to which you are entitled on your own behalf under:

(a) the Canada Pension Plan;

(b) the Quebec Pension Plan; or

(c) a similar plan in another country which has a reciprocal agreement with Canada or Quebec.

This does not include retirement benefits that were payable for each of the 12 months before a disability period.

(2) Benefits under any Workers' Compensation Act or similar law except for:

(a) permanent partial disability awards that were payable for each of the 12 months before a disability period; and

(b) benefits related to employment with another employer.

(3) Employer sponsored short term disability or sick leave benefits.

(4) Loss of income benefits under an automobile insurance plan, to the extent permitted by law.

(5) 50% of earnings received from an approved rehabilitation plan.


325156-B1 (2008-02-01.version32) 21

All source maximum provision:

Under this provision, your monthly benefit is reduced if the total of the following income and your monthly benefit exceeds the all source maximum shown in the Summary of Coverages. The reduction is the amount by which this total exceeds the all source maximum.

(1) Benefits to which another member of your family is entitled on the basis of your disability under:

(a) the Canada Pension Plan;

(b) the Quebec Pension Plan; or

(c) a similar plan in another country which has a reciprocal agreement with Canada or Quebec.

Benefits payable directly to the family member are not included.

(2) Loss of income benefits available through legislation to which you or another member of your family is entitled on the basis of your disability, except for Employment Insurance benefits and automobile insurance benefits.

(3) The wage loss portion of any criminal injury award, except for awards that included the long term disability income benefits available under this plan in the calculation of the award.

(4) Disability benefits under a plan of insurance available through an association, except for benefits that were payable for each of the 12 months before a disability period.

(5) Employment income, disability benefits, or retirement benefits related to any employment, except for:

(a) disability benefits that are prepayments of life insurance.

(b) benefits from retirement plans to which an employer has not contributed.

(c) any amount that is related to employment other than with the employer and that was payable for each of the 12 months before a disability period. All employment income, disability benefits, and retirement benefits resulting from the same employment are considered together in satisfying the 12-month condition as long as there is no interruption from one to the other. Waiting periods for disability benefits do not count as interruptions.

(d) employer sponsored short term disability or sick leave benefits.

(e) income from an approved rehabilitation plan. This income is considered under the offset and rehabilitation incentive provisions.

Termination pay, severance benefits, and any similar termination of employment benefits, including any salary paid in lieu of notice, are considered employment income under this provision.

If income under this provision is payable on a commission basis, the income used will not be reduced by commission related expenses.

If disability is a recurrence, employment related disability benefits which become payable after the disability period starts will be included under the offset provision rather than under this all source maximum provision.


325156-B1 (2008-02-01.version32) 22

Rehabilitation incentive provision:

Earnings received from an approved rehabilitation plan are not used to reduce your monthly benefit unless 50% of those earnings, your income from this plan, and the income described under the offset and all source maximum provisions would exceed:

(1) for taxable plans, 95% of your monthly earnings; and

(2) for non-taxable plans, 95% of your take-home pay.

If it does, your monthly benefit is reduced by the amount in excess of 95%.

H. INFLATION PROTECTION

The following provisions provide inflation protection.

Assessment:

In assessing your ability to be gainfully employed, Great-West Life will multiply your pre-disability take-home pay by the Consumer Price Index factor.

Recalculation:

The amount payable will be recalculated for inflation protection on the May 1st after the start of the benefit period and annually after that. On those dates:

(1) the then current amount payable will be multiplied by the Cost-of-Living Adjustment factor; and

(2) the following amounts will be multiplied by the Consumer Price Index factor:

(a) the all source maximum for purposes of recalculating both the monthly benefit for non-taxable plans and the amount payable for both taxable and non-taxable plans; and

(b) the income limit under the rehabilitation incentive provision.

Other income:

When the amount payable is recalculated, cost-of-living increases in the income described under the offset and all source maximum provisions, that take effect after the benefit period starts, are not included as income subject to the offset, all source maximum and rehabilitation incentive provisions.

This provision does not apply to earnings received from an approved rehabilitation plan.

Consumer Price Index factor:

The Consumer Price Index factor for an assessment or recalculation date is the ratio of the Consumer Price Index as of the January 1 before that date, to the Consumer Price Index as of the January 1 before the start of the benefit period.


325156-B1 (2008-02-01.version32) 23

Cost of Living Adjustment factor:

The Cost-of-Living Adjustment factor for a recalculation date is the lesser of:

(1) 1.05; and

(2) the ratio of the Consumer Price Index as of the January 1 before that date, to the Consumer Price Index as of 12 months earlier.

If the calculation of item (2) yields a factor in excess of 1.05, such excess will be applied in future years calculations.

Changes to the Consumer Price Index:

If there is a change in the method of calculating the Consumer Price Index:

(1) the Consumer Price Index will be used for the period preceding the change; and

(2) an appropriate measure of inflation will be used for the period after the change.

Consumer Price Index:

The Consumer Price Index means the all-item Consumer Price Index for Canada (not seasonally adjusted).

I. VOCATIONAL REHABILITATION

Vocational rehabilitation involves a training strategy or work related activity that:

(1) is designed to facilitate a disabled person's return to his or her job or other gainful employment; and

(2) is recommended or approved by Great-West Life.

In considering whether to recommend or approve a rehabilitation proposal, Great-West Life will assess such factors as the expected duration of disability, and the level of activity required to facilitate the earliest possible return to work.

The goal of a rehabilitation plan must be:

(1) to return the person to work in the same job;

(2) to return the person to work in a modified job with the same employer; or

(3) to return the person to work in a different job that capitalizes on transferable skills.

Participation commitment:

If you do not participate or cooperate in a rehabilitation plan that has been recommended or approved by Great-West Life, you will no longer be entitled to income benefits.

Time commitment:

The duration of a rehabilitation plan must be approved by Great-West Life. Once approved, your benefit period is guaranteed for that duration as long as you continue to participate and cooperate in the plan.


325156-B1 (2008-02-01.version32) 24

Employment income:

Employment income earned during a rehabilitation period will be considered under the offset and rehabilitation incentive provisions.

Expense benefit:

Reasonable expenses associated with a rehabilitation plan, other than usual employment expenses, may be paid for by Great-West Life at its discretion.

Expenses claimed under this provision must be pre-authorized by Great-West Life.

Limitation:

Vocational rehabilitation benefits are only available while you are entitled to income benefits.

J. MEDICAL COORDINATION

Medical coordination is a program that:

(1) is designed to provide cost effective, quality care;

(2) is designed to facilitate medical stability; and

(3) is recommended or approved by Great-West Life.

In considering whether to recommend or approve a medical coordination program, Great-West Life will assess such factors as the expected duration of disability, and the level of activity required to facilitate medical stability.

A medical coordination program may include the following services:

(1) consultation with the disabled person, members of the person's family, and the attending physician to gain further understanding of the treatment plan and its goals.

(2) comparison of the person's current treatment plan with generally accepted treatment standards for similar conditions and, where suitable, follow up identified alternatives with the attending physician.

(3) referral to professionals, including physician specialists, or facilities, for diagnosis or treatment.

Participation commitment:

If you do not participate or cooperate in a medical coordination program that has been recommended or approved by Great-West Life, you will no longer be entitled to income benefits.

Expense benefit:

Reasonable expenses associated with a medical coordination program may be paid for by Great-West Life at its discretion.

Expenses claimed under this provision must be pre-authorized by Great-West Life.

No benefits will be paid for any portion of the expense for which benefits are payable under a government plan.


325156-B1 (2008-02-01.version32) 25

Limitations:

Medical coordination benefits are only available while you are entitled to income benefits. Great-West Life will not cover medical coordination services after you have returned to work, unless you are receiving vocational rehabilitation benefits.

K. GENERAL LIMITATIONS

No benefits will be paid for:

(1) disability arising from a disease or injury for which you obtained medical care before you became covered. Medical care is considered to be obtained when you consult a physician, use medication on the advice of a physician, or receive other medical services or supplies.

(2) any period in which you do not participate or cooperate in a reasonable and customary treatment program.

A reasonable and customary treatment program is systematic treatment that:

(a) is performed or prescribed by a physician; and

(b) is of the nature and frequency usually required for the condition involved.

Where considered appropriate by Great-West Life for the severity of the condition, the treatment must be prescribed by and, if appropriate, performed or supervised by a certified specialist for the condition involved.

If substance abuse contributes to a person's disability, his treatment program must include participation in a recognized substance withdrawal program.

(3) any period after you fail to cooperate in applying for other disability benefits, reapplying for such benefits, or appealing decisions regarding such benefits, where considered appropriate by Great-West Life.

(4) any period after you fail to participate or cooperate in a rehabilitation plan that has been recommended or approved by Great-West Life.

(5) any period after you fail to participate or cooperate in a medical coordination program that has been recommended or approved by Great-West Life.

(6) any period after you fail to participate or cooperate in a medical or vocational assessment required by Great-West Life.

(7) the scheduled duration of a leave of absence. A leave of absence is considered to start on the date agreed upon by you and the employer.

This exclusion does not apply to any portion of a period of maternity leave during which the person is disabled as a result of pregnancy. If a child is born before a period of maternity leave is scheduled to start, the leave is considered to start on the date of birth.

(8) any period in which you are outside Canada. This exclusion does not apply during the first 30 days of an absence, or if Great-West Life pre-authorized the absence prior to your departure.


325156-B1 (2008-02-01.version32) 26

(9) any period of incarceration, confinement, or imprisonment by authority of law.

(10) disability arising from war, insurrection or voluntary participation in a riot.

L. NOTICE AND PROOF OF CLAIM

To permit prompt assessment, initial notice of claim should be submitted to Great-West Life no later than 10 days after disability starts.

Great-West Life will not be liable for claims for which initial notice is submitted more than 3 months after the earlier of:

(1) the end of the waiting period; and

(2) the date the contract terminates.

Benefits will only be payable for periods for which Great-West Life has received satisfactory proof that you are entitled to benefits.

You must provide information required to prove your entitlement to benefits and must also authorize Great-West Life to obtain information from other sources for this purpose.

Whenever Great-West Life requests information or authorization, it must be submitted within 3 months. If it is not submitted within this time, Great-West Life will not be liable for any further benefits.

Great-West Life will give you a written notice of assessment showing:

(1) whether or not benefits have been approved;

(2) whether or not further information is required; and

(3) if benefits have not been approved, the reasons for denial and the procedures you may follow to appeal.

Proof satisfactory to Great-West Life may be required to verify statements made to establish insurability.

Great-West Life, at its discretion and to the extent permitted by law, may pay another person on your behalf.

M. WAIVER OF PREMIUM

No premium is payable for your long term disability coverage during a disability benefit period.

Global medical assistance coverage

325156-B1 (2008-02-01.version32) 27

GLOBAL MEDICAL ASSISTANCE COVERAGE

FOR YOU AND YOUR QUALIFIED DEPENDENTS

COVERAGE

Global medical assistance is covered if:

(1) it is required as a result of a medical emergency arising while the covered person is travelling for vacation or business, or is travelling to or from an educational facility; and

(2) the covered person is covered by the government health plan in that person’s home province.

Coverage for travel within Canada is limited to emergencies arising more than 500 kilometres from the covered person’s home.

Assistance is provided through a worldwide communications network that operates 24 hours a day. The network assists in locating medical care and obtaining Great-West Life’s prior approval of covered services. The network can also approve on-site hospital payment when required for admission, to a maximum of $1,000.

A. COVERED SERVICES

The following services are covered subject to Great-West Life’s prior approval:

(1) Medical evacuation

Medical evacuation is covered if suitable local care is not available. If the covered person is travelling within Canada, coverage is provided for transportation to the nearest hospital where treatment is available. If the covered person is travelling outside Canada, coverage is provided for transportation to:

(a) the nearest hospital outside Canada where treatment is available; or,

(b) a hospital in Canada.

When services are covered under this coverage they are not covered under other coverages in this plan.

(2) Family assistance

Round trip economy class transportation and lodging are covered for one family member joining a covered person who will be hospitalized for more than 7 days while travelling provided that there was no family member travelling with the covered person.


325156-B1 (2008-02-01.version32) 28

(3) Travelling companion

Extra lodging costs are covered for one travelling companion when the return trip for the covered person and travelling companion is delayed because the covered person is hospitalized. No benefits are payable for extra lodging costs for a travelling companion if family assistance benefits are claimed under (2) for the same period of confinement.

(4) Transportation reimbursement

The cost of comparable return transportation home for a covered person and one travelling companion is covered if prearranged, prepaid return transportation is missed because the covered person is hospitalized. Any amount for which other compensation is available is not covered. A rental vehicle is not considered prearranged, prepaid return transportation.

(5) Death

In case of death, preparation of the covered person’s body and its return transportation home are covered.

(6) Unaccompanied minor children

Return transportation home is covered for minor children who had travelled with the covered person and who are left unaccompanied because of the covered person’s hospitalization or death. Return or round trip transportation for an escort for the children is also covered when considered necessary.

(7) Vehicle return

The cost of returning a covered person’s vehicle, whether private or rental, home or to the nearest appropriate vehicle rental agency is covered when sickness or injury prevents the covered person from driving. The maximum amount payable is $1,000. No benefits will be paid for vehicle return if transportation reimbursement benefits are claimed under (4) for the same period of confinement.

B. REFUND OF ON-SITE HOSPITAL PAYMENTS

Where on-site hospital payments exceed Great-West Life’s liability for that confinement under this group benefit plan, the covered person must refund the excess to Great-West Life. If the hospital confinement is not covered in this group benefit plan, Great-West Life is entitled to a full refund of the amount advanced.

C. LODGING LIMITATION

Benefits for lodging are limited to moderate quality accommodation for the area of hospitalization. Telephone expenses as well as taxicab and car rental charges are included. Meal expenses are not covered. The maximum amount payable for lodging expenses is $1,500 per confinement.


325156-B1 (2008-02-01.version32) 29

D. DISCLAIMER

Neither the communication network nor Great-West Life is responsible for:

(1) the availability, quantity, quality, or results of any medical treatment a person receives; or

(2) any unsuccessful attempts by a person to obtain medical services.

E. IDENTIFICATION CARDS

If a covered person’s coverage terminates for any reason, the employer is responsible for immediate recall of the global medical assistance identification cards.

F. LIMITATIONS


(1) expenses that private insurers are not permitted to cover by law.

(2) services the person is entitled to without charge by law or for which a charge is made only because the person has insurance coverage.

(3) expenses arising from war, insurrection, or voluntary participation in a riot.

G. EXTENSION OF BENEFITS

If the coverage of a covered person terminates for any reason and if the covered person is totally disabled on the date of termination, benefit payments for the expenses incurred as a result of that sickness will continue during the total disability as if such coverage had continued. Benefits will continue for a period of 90 days or, if earlier, to the date the individual becomes covered under any other group plan, whether issued by Great-West Life or another company.

"Totally disabled" and "total disability" means that the covered person, if an employee, is prevented solely because of sickness from engaging in any work for compensation or profit, or, if a dependent, is prevented solely because of sickness from engaging in all of the normal activities of a person of like age and sex, and who is in good health.


325156-B1 (2008-02-01.version32) 30

H. EXTENSION OF COVERAGE ON YOUR DEATH

(This extension does not apply to O.H.I.P. replacement benefits.)

If your dependents are covered under this coverage on the date of your death, their coverage will continue until the earliest of:

(1) 24 months from the date of your death, if you are an active employee, or

(2) indefinitely, if you are a retired employee;

(3) the end of the month the dependent is no longer a qualified dependent;

(4) the date that similar coverage is obtained elsewhere;

(5) the date this coverage is cancelled; and

(6) the date the contract is cancelled.

Part II. ASO coverages

325156-B1 (2008-02-01.version32) 31

PART II. ASO COVERAGES

The Pay-Direct Prescription Drug Plan, Extended Health Care Coverage and Dental Care Coverage described in this part of the group benefit plan are administered on behalf of the Contractholder by Great-West Life pursuant to Administrative Services Agreement (ASO) No. 57130 between the Contractholder and Great-West Life. These coverages are not insured by Great-West Life. Because these coverages are not insured, they are not protected by Assuris.


325156-B1 (2008-02-01.version32) 32

SUMMARY OF COVERAGES

COVERAGES FOR YOU AND YOUR QUALIFIED DEPENDENTS

PAY-DIRECT PRESCRIPTION DRUG PLAN

The drug plan is described in detail on later pages.

Covered percentage, as follows:

For retirees: Covered percentage is combined with Extended Health Care Coverage - please see below.

For all other employees: Great-West Life pays 80% of the total amount payable* for the prescription or refill for the first $605 per covered person or $1,210 per covered family per calendar year (combined with the Extended Health Care Coverage), and 100% thereafter.

* Any dispensing fee over $7.00, included in the total amount payable, is not applied to the first $605 per covered person or $1,210 per covered family per calendar year.

EXTENDED HEALTH CARE COVERAGE

Covered percentage: 80% of the first 5 days of hospital expenses, 100% thereafter. 80% of the first 10 days of nursing charges; 100% thereafter. 100% of ambulance charges. 100% of out of Province/Canada charges.

For all other eligible charges Great-West Life pays 80% of the first $605 per covered person or $1,210 per covered family per calendar year (combined with the Pay-Direct Prescription Drug Plan), and 100% thereafter.

Overall lifetime maximum for retirees residing in Canada, but outside of Ontario: $80,000. However, benefits for out-of-country expenses are limited to $40,000.

Overall lifetime maximum for all other employees: Unlimited.

Benefits provided Maximum amount payable

(The complete list is shown on later pages.)

(per covered person)

Hospital Semi-private room daily rate. Private room daily rate, outside your province of residence, when medically necessary and referred by a physician (M.D.) in Canada.


325156-B1 (2008-02-01.version32) 33

Expenses incurred while outside the province of residence or outside Canada, as follows: (60 days coverage per trip for retirees)

Treatment of a medical emergency A lifetime maximum of $1,000,000.

Specialized treatment not available in the province of residence or in Canada

A lifetime maximum of $50,000.

Psychologist or **social worker with a master's degree in social work

An overall maximum of $585 in a calendar year.

Chiropractor $12 per visit for the first 15 visits in a calendar year. Charges for subsequent visits in the same calendar year are reasonable and customary. The maximum amount payable in a calendar year is $585.

Naturopath, osteopath, podiatrist or chiropodist

$585 per practitioner in a calendar year

*Reimbursement will take place after the O.H.I.P. maximum is reached.

**Massage therapist $585 in a calendar year.

**Nutritional counselling $585 in a calendar year.

**Private duty nursing in the home $17,702 in a calendar year.

Physiotherapist or occupational therapist An overall maximum of $585 in a calendar year.

**Speech therapist $585 in a calendar year.

**Custom-made orthopedic shoes 3 pairs every 2 years, at a reasonable and customary charge.

**Orthotics, including repairs $585 in a calendar year.

Hearing aids $585 per ear, every 5 years.

*Reimbursement will take place after the claim has been reviewed by the Assistive Devices Program.

**Lenses required as a result of cataract surgery, or when a covered person lacks an organic lens

Reasonable and customary charge.

**Elastic support stockings 12 pairs in a calendar year.


325156-B1 (2008-02-01.version32) 34

**Wigs required as a result of a medical issue

One in a covered person's lifetime.

**Breast prosthesis Reasonable and customary charge.

**Surgical brassieres 4 in a calendar year.

**Insulin infusion pump Once every 5 calendar years, reasonable and customary charge.

** A written authorization is required from a physician (M.D.) unless the expense is for a devise that has been accepted by ADP.

In addition to the benefits described above, the Extended Health Care Coverage will pay for charges for which reimbursement would have been made by the Ontario Health Insurance Plan (O.H.I.P.) if the covered person was eligible for O.H.I.P., provided the covered person:

(1) is a resident alien in Canada,

(2) is an employee who commenced employment with the employer immediately upon entering Canada, or is a dependent of the employee, and

(3) was ineligible under O.H.I.P. when the eligible charge was incurred.

DENTAL CARE COVERAGE

(Applicable to Faculty, Non-Union Staff, Union Bi-Weekly, Church College and Centre and Affiliate with Full Benefits)

Covered Percentage:

- - -

for basic coverage for major coverage for orthodontic coverage

80% 50% 50%

Fee Guide: The dental fee guide in effect in the covered person’s province of residence two years before the date the treatment is rendered.

Benefit Maximums:

- - -

for basic coverage for major coverage for orthodontics

$1,927 per calendar year $2,904 per calendar year $2,904 lifetime

Termination: At the end of the year you attain age 69 or your retirement, if earlier.

Pay-direct prescription drug plan

325156-B1 (2008-02-01.version32) 35

PAY-DIRECT PRESCRIPTION DRUG PLAN


Your Pay-Direct Prescription Drug Plan covers the eligible charges for drugs, medicines and certain supplies when prescribed by a physician or other person entitled by law to prescribe them, dispensed by a licensed pharmacist and made necessary by a sickness or injury.

To have a prescription filled for yourself or a qualified dependent, take the prescription to a participating pharmacy and present it, along with your prescription drug card, to the pharmacist and the prescription will be filled.

Do not lend your prescription drug card to anyone outside your immediate family and do not leave it at the pharmacy.

If your employment ends, you are no longer eligible for this coverage. You must return your prescription drug card to your employer.

A. SERVICES PROVIDED

The services described in this coverage are provided by the pharmacy benefits manager appointed by Great-West Life and are subject to the agreement between Great-West Life and the pharmacy benefits manager as may be amended from time to time.

B. PAYMENT OF BENEFITS

For all eligible charges, benefits will be equal to the covered percentage shown in the Summary of Coverages. Benefits for drug claims submitted through the pharmacy benefits manager’s electronic claims system will be issued to the pharmacy benefits manager.

The eligible charge for interchangeable products is limited to the cost of the lowest priced item in the applicable generic category plus a professional fee, unless the prescription has been written by brand name and directed by the prescriber not to be interchanged. If it has, the actual expense will be considered eligible for payment under the Health Disciplines Act – Pharmacy regulations as long as the prescription bears the notation “DO NOT PRODUCT SELECT”, “NO SUB”, or “NO SUBSTITUTION” on the actual script in the prescriber’s own handwriting.

Covered charges for drugs eligible under any government drug plan are limited to any amounts the employee is required to pay for himself or his family under the government plan.


325156-B1 (2008-02-01.version32) 36

C. ELIGIBLE CHARGES

Eligible charges are the charges actually made to the covered person for the following drugs, medicines and supplies.

(1) drugs that require a prescription according to:

(a) the Food and Drugs Act, Canada; or

(b) provincial legislation in effect where the drug is dispensed.

Oral contraceptives are covered.

(2) drugs that must be injected, including vitamins, insulins and allergy extracts. Syringes for self-administered injections are also covered.

(3) disposable needles for use with non-disposable insulin injection devices, lancets, and test strips.

(4) extemporaneous preparations or compounds if one of the ingredients is a covered drug.

(5) vaccines used to prevent disease.

(6) certain drugs that would not otherwise qualify for coverage if they are identified in writing by the policyholder and they are approved for payment by Great-West Life.

(7) The following non-prescription items are not covered:

(a) atomizers, appliances or prosthetic devices.

(b) first aid or diagnostic supplies or testing equipment.

(c) non-disposable insulin delivery devices or spring loaded devices used to hold blood letting supplies.

(d) delivery or extension devices for inhaled medications.

(e) oral vitamins, minerals, dietary supplements, homeopathic preparations, infant formulas, or injectable total parenteral nutrition solutions, whether or not prescribed for a medical reason, except where federal or provincial law requires a prescription for their sale.

(f) diaphragms, condoms, contraceptive jellies, foams, sponges, or suppositories, contraceptive implants, or appliances normally used for contraception, whether or not prescribed for a medical reason.

(8) drugs used to treat erectile dysfunction.

D. BENEFIT MAXIMUMS

Benefits for fertility drugs are limited to $3,000 in a person's lifetime.


325156-B1 (2008-02-01.version32) 37

E. EXCLUSIONS


(1) any drug that does not have a drug identification number as defined by the Food and Drugs Act, Canada.

(2) any single purchase of a drug that would not reasonably be consumed or used within 90 days.

(3) drugs dispensed by a dentist or clinic or by a non-accredited hospital pharmacy.

(4) drugs dispensed during treatment as an inpatient or an outpatient in a hospital.

(5) non-injectable allergy extracts.

(6) drugs that are considered cosmetic, such as topical minoxidil or sunscreens, whether or not prescribed for a medical reason.

(7) smoking cessation products.

(8) drugs or medicines used in the treatment of obesity.


(10) drugs, medicines or supplies for which a charge is made only because the person has insurance coverage.

(11) any portion of drugs, medicines or supplies which the person is entitled to receive, or for which the person is entitled to a benefit or reimbursement, by law or under a plan that is legislated, funded, or administered in whole or in part by a government (“government plan”), without regard to whether coverage would have otherwise been available under this plan. In this exclusion, government plan does not include a group plan for government employees.

(12) drugs, medicines or supplies that do not represent reasonable treatment.

(13) drugs, medicines or supplies associated with covered items, unless specifically listed as a covered charge.

(14) drugs, medicines or supplies associated with:

(a) treatment performed for cosmetic purposes only;

(b) recreation or sports rather than with other regular daily living activities.

(15) drugs, medicines or supplies received out of province unless:

(a) the person is covered by the government health plan in his home province; and

(b) Great-West Life would have paid benefits for the same services or supplies if they had been received in the person's home province.



325156-B1 (2008-02-01.version32) 38

F. TRIAL DRUG PROGRAM

New prescriptions for selected drugs are subject to an initial trial quantity and monitoring by the dispensing pharmacist to ensure the medication is effective and tolerated by the patient.

G. CONCURRENT DRUG UTILIZATION REVIEW

In Canada claims for covered drugs submitted electronically to the pharmacy benefits manager are subject to concurrent drug utilization review at point-of-sale to determine if:

(1) drug interactions between a prescribed drug and another drug already being taken by the patient may occur;

(2) a prescribed drug may be harmful to a patient;

(3) the frequency of refills is reasonable; or

(4) the duration and dosage of the therapy is within recommended limits.

Based on the outcome of the review, a pharmacist may refuse to dispense the drug as prescribed.

Neither Great-West Life nor the pharmacy benefits manager makes any guarantees about the accuracy of the patient information provided for the concurrent drug utilization review or about the review results, nor are they responsible for any decision made by the pharmacist as a result of the review process.

H. PROOF OF CLAIM

Written proof of the loss on which a claim may be based must be given to Great-West Life within 365 days after the end of the calendar year in which the expense was incurred.

Extended health care coverage

325156-B1 (2008-02-01.version32) 39

EXTENDED HEALTH CARE COVERAGE


DEFINITIONS

Where used in this coverage, the following words or phrases have the meanings set forth below:

(1) “Chiropractor” means a licensed chiropractor who has a designation of DC (Doctor of Chiropractic.

(2) “Dietician or nutritionist” means a registered dietician who has a designation of RD (Registered Dietician), RDt (Registered Dietician), RDN (Registered Dietician Nutritionist), PDt (Professional Dietician), or DT.P. (Dietetiste Professionnelle), provided the service is prescribed by a duly licensed doctor of medicine (M.D.).

(3) "Eligible charges" means the reasonable and customary charges actually made to the covered person for the medical services and supplies described in section B., provided the services and supplies are medically necessary for the care and treatment of a covered person's sickness or injury and are ordered by a physician unless otherwise stated, and the charges:

(a) exceed the amount payable under any government medical, health or hospital services plan or, if the person is not covered under such a plan, exceed the amount that would have been payable by the plan of the province or territory in which the covered person resides;

(b) exceed the amount payable under any other coverage of the contract, any Workers' Compensation Act or similar law, or any other source, other than an individual policy issued by another company; and

(c) are those for which Great-West Life is not prohibited by law from providing.

Not withstanding the provisions described in this item (1), the Extended Health Care Coverage will pay for charges for which reimbursement would have been made by the Ontario Health Insurance Plan (O.H.I.P.) if the covered person was eligible for O.H.I.P., provided the covered person

(a) is a resident alien in Canada,

(b) is an employee who commenced employment with the employer immediately upon entering Canada, or is a dependent of the employee, and

(c) was ineligible under O.H.I.P. when the eligible charge was incurred.


325156-B1 (2008-02-01.version32) 40

(4) "Hospital" means:

(a) an institution that is legally operated, is supervised by a staff of physicians, has registered nurses (R.N.) in attendance 24 hours a day, provides a broad range of 24 hours a day medical and surgical services for sick and injured persons, and which is not, other than incidentally, a nursing home or a facility for rest or for the aged, a convalescent or rehabilitation hospital, or

(b) an institution accredited as a hospital by the Canadian Council on Hospital Accreditation or approved for resident inpatient care under a provincial services program.

(5) "Massage therapist" means a qualified massage therapist who has a designation of MT (Massage Therapist), LMT (Licensed Massage Therapist), CM (Certified Massotherapist), RMT (Registered Massage Therapist), L.C.S.P. (PHYS)/L.C.S.P. (ASSOC) (The London and Counties Society of Physiologists), or AMTHP/AMTWP (Association of Massage Therapists and Holistic Practitioners). For services provided in Quebec, this includes qualified massage therapists who have a designation of AMS (Association des massotherapeutes du Quebec). For services provided in Alberta, this includes qualified massage therapists who have a designation of A.S.M.T. For services provided in Manitoba, this includes qualified massage therapists who have a designation of H.T.M.T. (Holistic Therapists and Massage Therapists Association), provided the service is prescribed by a duly licensed doctor of medicine (M.D.).

(6) "Medical emergency" means an unforeseen event occurring while a covered person is travelling which causes that person injury or sickness. Such travel must be for the purpose of business or pleasure and not in any way for the purpose of obtaining hospital or medical treatment.

(7) "Medically necessary" means the service or supply is ordered by a physician and is commonly and customarily recognized throughout the physician's profession as appropriate in the treatment of the patient's diagnosed sickness, injury or condition. The service or supply must not be educational, experimental or investigational in nature, nor provided primarily for the purpose of medical or other research.

In the case of a hospital confinement, the duration and the services and supplies will be considered necessary only to the extent Great-West Life determines them to be:

(a) related to the treatment of the sickness or injury; and

(b) not allocable to the scholastic education or vocational training of the patient.

(8) “Occupational therapist” means a qualified occupational therapist.

(9) "Osteopath" means a qualified osteopath who has a designation of DO (Doctor of Osteopathy).

(10) "Physician" means a duly licensed doctor of medicine (M.D.). Physician also means a duly licensed dentist, podiatrist, chiropodist, chiropractor, osteopath, naturopath, physiotherapist, or a psychologist practising within the scope of his or her profession who is licensed by the licensing and registration authority in the jurisdiction where the service is rendered.

(11) “Physiotherapist” means a licensed physiotherapist who has a designation of PT (Physiotherapist).


325156-B1 (2008-02-01.version32) 41

(12) “Podiatrist or chiropodist” means a licensed podiatrist or chiropodist, who has a designation of D.Ch (Diploma in Chiropody), S.R. CH (State Registered Chiropodist), D.Pod.M (Diploma in Podiatric Medicine), DPM (Doctor of Podiatric Medicine), or M.S.S. CH (Member of Society of Surgical Chiropodists).

(13) “Psychologist” means a licensed, certified, registered or chartered psychologist who has a designation of Phd. (c) psych or a Master’s Degree in psychology (MA).

(14) "Reasonable and customary charge" means the usual charge of the provider for the service or supply, in the absence of coverage, but not more than the prevailing charge in the area for a like service or supply. A like service or supply is one of the same nature and duration, requires the same skill, and is performed by a provider of similar training and experience.

(15) "Social worker" means a qualified social worker with a designation of M.S.W. (Master of Social Work), provided the service is prescribed by a duly licensed doctor of medicine (M.D.).

(16) "Speech therapist" means a qualified speech therapist, provided the service is prescribed by a duly licensed doctor of medicine (M.D.).

A. PAYMENT OF BENEFITS

A benefit will be paid if a covered person incurs eligible charges in connection with the services and supplies described in section B. while covered under this coverage. A charge is considered to be incurred on the date of the service or purchase for which the charge is made.

For all eligible charges, benefits will be equal to the covered percentage (shown in the Summary of Coverages).

B. ELIGIBLE CHARGES

Eligible charges are the reasonable and customary charges actually made to the covered person for the following medically necessary services and supplies:

(1) Hospital

Charges for room and board in a hospital in Canada, up to the maximum amount payable shown in the Summary of Coverages.

Charges for confinement in the Donwood Institute and Homewood Health Centre are limited to a maximum of 60 days each in a covered person's lifetime.

Excluding

(a) charges which are primarily for custodial care such as chronic care facilities and nursing homes, and

(b) charges in a convalescent or rehabilitation hospital.

(2) Services of a duly licensed doctor of medicine (M.D.) for treatment of a medical emergency while the covered person is travelling outside the province or territory of residence but within Canada.


325156-B1 (2008-02-01.version32) 42

(3) Non-emergency medical services and supplies incurred while out of Canada for a covered person who is on an approved sabbatical.

(4) Expenses incurred while outside the province of residence or outside Canada

Charges for expenses incurred while outside the province of residence or outside Canada will be eligible provided the expense is recommended by a physician on account of:

(a) treatment of a medical emergency while travelling outside the province of residence or outside Canada; or

(b) specialized treatment not available in the province of residence or in Canada when the covered person is referred outside the province of residence or outside Canada by his or her regularly attending physician.

The eligible charges will be equivalent to the charges actually made to the covered person minus any charge covered by any government plan, up to the maximum amount payable shown in the Summary of Coverages.

Eligible expenses include:

(a) public ward accommodation and other services and supplies furnished by the hospital;

(b) services of a physician;

(c) emergency outpatient services;

(d) any other medically necessary services and supplies which would otherwise be covered under this coverage.

(5) Ambulance service to and from the nearest medical facility equipped to provide adequate treatment.

(6) Services of a dentist for dental treatment of injuries to sound, vital, natural teeth when caused by a direct accidental blow to the mouth, occurring while a covered person (but not when caused by an object wittingly or unwittingly placed in the mouth), provided the charges are incurred within 12 months of the accident.

(7) Services of a psychologist or a social worker with a Master of Social Work (M.S.W.) degree in connection with the diagnosis and treatment of mental, nervous or emotional disorders, up to the maximum amount payable shown in the Summary of Coverages.

(8) Services of a chiropractor, naturopath, osteopath, podiatrist, or chiropodist, including one X-ray examination per specialty, up to the maximum amount payable shown in the Summary of Coverages.

Limitation

For residents of Ontario, benefits for the services of a podiatrist will not be payable until the maximum yearly allowance for those services under the provincial health insurance plan has been paid on behalf of a covered person.

(9) Treatment by a registered massage therapist, up to the maximum amount payable shown in the Summary of Coverages.


325156-B1 (2008-02-01.version32) 43

(10) Nutritional counselling services by a registered professional dietician or nutritionist, who is a member of the Ontario Dietetic Association, up to the maximum amount payable shown in the Summary of Coverages.

(11) Private duty professional nursing services in the home by a registered graduate nurse, a registered nursing assistant, a registered practical nurse, or similarly licensed person, other than a close relative, provided (a) the service is prescribed by a duly licensed doctor of medicine (M.D.), and (b) intensive care nursing is required in the treatment of an acute sickness; up to the maximum amount payable shown in the Summary of Coverages.

Exclusion

Benefits will not be payable when the services actually furnished:

(a) are mainly custodial;

(b) are mainly to assist the covered person with the functions of daily living or to dispense oral medication; or

(c) could be furnished properly by someone who does not have the professional qualifications stated above.

(12) Treatment by a physiotherapist or occupational therapist, up to the maximum amount payable shown in the Summary of Coverages.

(13) Treatment by a speech therapist, up to the maximum amount payable shown in the Summary of Coverages.

(14) Custom-made foot orthotics including repairs, and custom-fitted orthopedic shoes, including modifications to orthopedic footwear, when prescribed by a physician, podiatrist or chiropodist, up to the maximum amount payable shown in the Summary of Coverages.

(15) Purchase, or replacement of hearing aids (excluding batteries), up to the maximum amount payable shown in the Summary of Coverages.

(16) Lenses required as a result of cataract surgery, up to the maximum amount payable shown in the Summary of Coverages.

(17) Intra-uterine devices inserted by a physician.

The requirement that the service or supply is necessary on account of sickness of a covered person does not apply to this item.


325156-B1 (2008-02-01.version32) 44

(18) Other services and supplies:

(A written authorization is required from a physician unless the expense is for a devise that has been accepted by ADP.) Artificial limbs, larynx, and eyes (payment for a myoelectric or sports prosthesis is

limited to the amount payable for a standard type artificial limb). Eyes, splints, trusses, casts, cervical collars, and braces. Catheters and urinary kits. Colostomy and ileostomy supplies. Tracheotomy supplies. Crutches, canes, walkers. and stump socks. Apnea monitors and aerochambers. Glucometer. Oxygen and rental of equipment for its administration. Respirator, surgical bandages, and dressings. Blood and blood plasma not replaced by or for the patient. Radium and radioactive isotope treatments. X-ray examinations and therapy and diagnostic laboratory procedures. Electronic heart pacemaker. Blood pressure devices. Rental or purchase (and repairs) of a hospital bed and a standard-type wheelchair.

(Electric wheelchairs and electric hospital beds are only payable when the attending specialist recommends a power driven unit because of a medical necessity.)

External breast prosthesis (following a mastectomy), up to the maximum amount payable shown in the Summary of Coverages.

Surgical brassieres, up to the maximum amount payable shown in the Summary of Coverages.

Surgical elastic or compression stockings, up to the maximum amount payable shown in the Summary of Coverages.

Wigs required as a result of a medical issue, up to the maximum amount payable shown in the Summary of Coverages.

Insulin infusion pump, up to the maximum amount payable shown in the Summary of Coverages.

C. OVERALL LIFETIME MAXIMUM

Benefits payable are subject to the overall lifetime maximum (shown in the Summary of Coverages) per covered person.


325156-B1 (2008-02-01.version32) 45

D. EXCLUSIONS

(1) Any charges incurred in connection with:

(a) Commission of, or attempt to commit, any criminal offence but not when injuries are sustained as a result of driving a vehicle when the covered person's blood contained more than 80 milligrams of alcohol in 100 millilitres of blood (.08).

(b) Intentionally self-inflicted injuries.

(c) Sickness due to war or any act of war, civil commotion, insurrection or hostilities of any kind.

(d) Rest cures, travel for health reasons, periodic checkups and examinations, or pregnancy tests.

(e) Telephone consultations made by a physician with respect to a person's sickness or injury.

(2) Any charges incurred for:

(a) Services or supplies dispensed by a person who normally resides with the covered person or who is related to the covered person by blood or marriage.

(b) Physicians' services or X-ray examinations involving one or more teeth, the tissue or structure around them, the alveolar process or the gums. This applies even if a condition requiring any of these services involves a part of the body other than the mouth such as the treatment of temporomandibular joint dysfunctions (TMJD) or malocclusion involving joints or muscles by methods, including, but not limited to, crowning, wiring or repositioning teeth. This does not apply to a charge made for dental treatment described in section B.

(c) Services or supplies to the extent that they are available under any government medical, health or hospital services plan or where such a plan prohibits payment.

(d) Services or supplies for which the covered person is not required to make payment, or where payment is received as a result of legal action or settlement.

(e) Services or supplies to the extent that they are payable or would have been payable under any Workers' Compensation Act or similar law, had timely pursuit been made.

(f) Services or supplies to the extent that such services or benefits for such services are available under any plan or program established pursuant to the laws or regulations of any government, including any motor vehicle no fault coverage required by statute.


325156-B1 (2008-02-01.version32) 46

E. EXTENSION OF BENEFITS

If the coverage of a covered person terminates for any reason and if the covered person is totally disabled on the date of termination, benefit payments for the expenses incurred as a result of that sickness will continue during the total disability as if such coverage had continued. Benefits will continue for a period of 90 days or, if earlier, to the date the individual becomes covered under any other group plan, whether issued by Great-West Life or another company.

"Totally disabled" and "total disability" means that the covered person, if an employee, is prevented solely because of sickness from engaging in any work for compensation or profit, or, if a dependent, is prevented solely because of sickness from engaging in all of the normal activities of a person of like age and sex, and who is in good health.

F. EXTENSION OF COVERAGE ON YOUR DEATH

(This extension does not apply to O.H.I.P. replacement benefits.)

If your dependents are covered under this coverage on the date of your death, their coverage will continue until the earliest of:

(1) 24 months from the date of your death, if you are an active employee, or

(2) indefinitely, if you are a retired employee;

(3) the end of the month the dependent is no longer a qualified dependent;

(4) the date that similar coverage is obtained elsewhere;

(5) the date this coverage is cancelled; and

(6) the date the contract is cancelled.

G. PROOF OF CLAIM

Written proof of the loss on which a claim may be based must be given to Great-West Life within 365 days after the end of the calendar year in which the expense was incurred.

Dental care coverage

325156-B1 (2008-02-01.version32) 47

DENTAL CARE COVERAGE


A. ASSESSMENT RESPONSIBILITY

Great-West Life has full responsibility for the assessment of a person’s entitlement to benefits.

B. ASSESSMENT STANDARD

All services and supplies covered under this coverage must represent reasonable treatment. Unless otherwise specified, dental treatment is both described and assessed according to the Canadian Dental Association Uniform System of Coding and List of Services.

Reasonable treatment

Treatment is considered reasonable if it is:

(1) recognized by the Canadian Dental Association;

(2) proven to be effective;

(3) performed by a dentist or under a dentist’s supervision, performed by a dental hygienist entitled by law to practise independently, or performed by a denturist; and

(4) of a form, frequency, and duration essential to management of the person’s health.

C. AMOUNT PAYABLE

A benefit will be paid for covered expenses that are incurred while the person is covered for them.

Covered expenses are the lesser of actual charges or customary charges for covered services and supplies.

Customary charges are the lowest of:

(1) prices shown for a general practitioner in the dental fee guide identified in the summary of coverages. Denturist fee guides are applicable when services are provided by a denturist. Dental hygienist fee guides are applicable when services are provided by a dental hygienist practicing independently. Specialist fee guides are applicable when a specialist provides services within his specialty.

(2) representative prices in the area where the treatment was provided.

(3) maximum prices established by law.


325156-B1 (2008-02-01.version32) 48

Benefits will be equal to the covered percentage shown in the summary of coverages.

Benefits are subject to any maximums identified for the covered services or supplies and to the orthodontic lifetime maximum.

Frequency limitations or maximums expressed in years refer to 12-month periods if calendar year is not indicated.

For the purposes of calculations made under this coverage, expenses other than orthodontic expenses are considered to be incurred when treatment is completed.

Orthodontic expenses are considered to be incurred on a periodic basis throughout the course of treatment.

Calendar year maximum

The maximum amount payable under this coverage for dental expenses incurred for one covered person in a calendar year, except those incurred for orthodontics, is shown in the summary of coverages.

D. PRE-DETERMINATION OF DENTAL CARE BENEFITS

To determine the extent of benefits provided under this coverage, it is recommended that a person submit a treatment plan to Great-West Life before having dental treatment that will cost $200 or more.

On receipt of the treatment plan, Great-West Life will advise the person of the estimated amount payable under this contract. This pre-determination of benefits is only valid for 90 days.

A treatment plan must contain the dental service provider’s confirmation of:

(1) the recommended treatment for complete correction of the person's condition;

(2) the approximate date of completion; and

(3) the estimated cost.

E. COVERED SERVICES

BASIC COVERAGE

Basic coverage is provided for the services described below.

Diagnostic Services

The following diagnostic services are covered:

(1) one complete oral examination every 24 months.

(2) oral pathology, periodontal, surgical, prosthodontic, and endodontic examinations.

(3) limited oral examinations once every 9 months, except that only one limited oral exam is covered in any year that a complete examination is also performed.

(4) limited periodontal examinations once every 9 months.


325156-B1 (2008-02-01.version32) 49

(5) specific and emergency examinations.

(6) complete series of intra-oral radiographs, once every 24 months.

(7) bitewing films, limited to once every 9 months.

(8) intra-oral radiographs.

(9) panoramic radiograph every 3 years.

(10) sialography.

(11) extra-oral radiographs other than panoramic and sialography.

(12) radiopaque dyes used to demonstrate lesions.

(13) interpretation of radiographs or models from another source.

(14) microbiological, histological, cytological, and pulp vitality tests.

(15) laboratory reports.

(16) consultation with patient.

No benefits will be paid for duplicate radiographs under this coverage.

Preventive Services

The following preventive services are covered:

(1) polishing once every 9 months.

(2) scaling, limited to a maximum combined with periodontal root planing of 16 time units a calendar year.

(3) topical application of fluoride once every 9 months.

(4) oral hygiene instruction once in a covered person’s lifetime.

(5) pit and fissure sealants.

(6) space maintainers. Acid etched pontic type space maintainers are covered only when provided for missing central and lateral teeth.

(7) maintenance of space maintainers.

(8) appliances for the control of harmful habits, including related observations, adjustments, repairs, alterations, and removal.

(9) finishing restorations.

(10) interproximal disking.

(11) recontouring of teeth.

A time unit is considered to be a 15-minute interval or any portion of a 15-minute interval.

Where coverage is limited by time units but fees are not described in terms of time units by either the fee guide in effect where treatment is rendered or the fee guide specified by this plan, each incident of service is considered one time unit, regardless of its duration.


325156-B1 (2008-02-01.version32) 50


(1) custom fluoride appliances.

(2) audio visual oral hygiene instruction.

(3) nutritional counselling.

Minor Restorative Services

The following minor restorative services are covered:

(1) caries, trauma and pain control.

(2) amalgam and tooth-coloured fillings. Replacement fillings are covered only if the existing filling is at least 12 months old and required due to breakdown or recurrent decay or the existing filling is amalgam and the patient is allergic to amalgam.

(3) retentive pins and prefabricated posts for fillings.

(4) prefabricated crowns.

Endodontic Services

Covered endodontic services include but are not limited to:

(1) treatment of the pulp chamber

(2) root canal therapy.

(3) apexification.

(4) periapical services. Apicoectomies are covered for permanent teeth only.


(1) isolation of teeth.

(2) enlargement of pulp chambers.

(3) endosseous intra coronal implants.

Periodontal Services

Covered periodontal services include but are not limited to:

(1) root planing, limited to a maximum combined with preventive scaling of 16 time units a calendar year.

(2) periodontal surgery.

(3) occlusal adjustment and equilibration, limited to a combined maximum of 8 time units a calendar year.

(4) periodontal appliances, including adjustments, relines, and repairs.


(1) desensitization.

(2) topical application of microbial agents.

(3) subgingival periodontal irrigation.


325156-B1 (2008-02-01.version32) 51

(4) charges for post surgical treatment.

(5) periodontal re-evaluations.

Denture Maintenance

The following denture maintenance services are covered:

(1) denture relines for dentures at least 6 months old, once every 3 years. If a separate charge is made for relines in connection with immediate dentures, the 6-month restriction is waived.

(2) denture rebases for dentures at least 2 years old, once every 3 years.

(3) resilient liner in relined or rebased dentures after the 3-month post-insertion care period has elapsed, once every 3 years.

(4) denture adjustments after the 3-month post-insertion care period has elapsed, once a year.

(5) denture repairs and additions and resetting of denture teeth after the 3-month post-insertion care period has elapsed.

Oral Surgery

Covered oral surgery includes but is not limited to:

(1) removal of teeth.

(2) surgical exposure of teeth.

(3) the following procedures for remodelling and recontouring oral tissues:

(a) minor alveoloplasty;

(b) gingivoplasty and stomatoplasty.

(4) surgical incisions.

(5) surgical excision of tumors, cysts, and granulomas.

(6) treatment of fractures, including related bone grafts to the jaw.

(7) treatment of maxillofacial deformities, including related bone grafts to the jaw and cheiloplasty.

Palatal obturators, although not listed with oral surgery in the Canadian Dental Association Uniform System of Coding and List of Services, are also covered under this provision.


(1) implantology.

(2) surgical movement of teeth.

(3) services performed to remodel or recontour oral tissues, other than those listed above. Services for remodelling and recontouring oral tissues are covered under major coverage.

(4) alveoloplasty or gingivoplasty performed in conjunction with extractions.


325156-B1 (2008-02-01.version32) 52

Adjunctive Services

The following adjunctive services are covered:

(1) minor remedies for relief of dental pain when provided on an emergency basis.

(2) therapeutic injections.

(3) anesthesia required in relation to covered services. The provision of general anesthetic facilities, equipment, and supplies is covered only when a separate anesthetist is required.

No benefits will be paid for hypnosis or acupuncture.

MAJOR COVERAGE

Major coverage is provided for the services described below.

Crowns and Onlays

Crowns and onlays are covered when a tooth has extensive structural loss that cannot be adequately restored using other procedures. The following crowns and related items are covered:

(1) metal, plastic, porcelain, and ceramic crowns. Coverage for crowns on molars is limited to the cost of metal crowns. Coverage for complicated crowns is limited to the cost of standard crowns.

(2) onlays. Coverage for tooth-coloured onlays on molars is limited to the cost of metal onlays.

(3) posts, cores, and pins related to covered crowns.

(4) copings related to covered crowns.

(5) repairs to covered tooth-coloured materials.

(6) removal and recementation of crowns and onlays.

Replacement crowns and onlays are covered when the existing restoration is at least 5 years old and cannot be made serviceable.


(1) veneers.

(2) recontouring existing crowns.

(3) staining porcelain.

(4) inlays, except as provided under alternative benefits.

If a crown or onlay is provided when a tooth could have been adequately restored using other procedures, alternative benefits will be provided based on coverage for fillings.

If inlays are provided, alternative benefits will be provided based on coverage for fillings.


325156-B1 (2008-02-01.version32) 53

Dentures and Bridgework

The following appliances are covered when required to replace one or more teeth extracted while you are covered for major coverage.

(1) standard complete dentures.

(2) standard cast or acrylic partial dentures.

(3) complete overdentures or bridgework when standard complete or partial dentures are not viable treatment options. Coverage for tooth-coloured retainers and pontics on molars is limited to the cost of metal retainers and pontics.

Replacement appliances are also covered when:

(1) the existing appliance is a covered temporary appliance.

(2) the existing appliance is at least 5 years old and cannot be made serviceable. If the existing appliance is less than 5 years old, a replacement will still be covered if the existing appliance becomes unserviceable while you are covered for major coverage as a result of:

(a) the placement of an initial opposing appliance; or

(b) the extraction of additional teeth. If additional teeth are extracted but the existing appliance can be made serviceable, coverage is limited to the replacement of the additional teeth.

Alternative Benefits

If overdentures or initial bridgework is provided when standard complete or partial dentures would have been a viable treatment option, alternative benefits will be provided based on coverage for:

(1) in the case of overdentures, standard complete dentures.

(2) in the case of initial bridgework:

(a) a standard cast partial denture; and

(b) restoration of abutment teeth when required for purposes other than bridgework.

If additional bridgework is performed in the same arch within 5 years, alternative benefits will also be provided for the additional bridgework based on coverage for:

(1) addition of teeth to a denture; and

(2) restoration of abutment teeth when required for purposes other than bridgework.

Alternative benefits will be provided for the following appliances based on coverage for standard dentures or bridgework:

(1) equilibrated and gnathological dentures.

(2) dentures with stress breaker, precision, and semi-precision attachments.

(3) dentures with swing lock connectors.

(4) partial overdentures.

Alternative benefits will be provided for dentures and bridgework related to implants based on coverage for standard bridgework.


325156-B1 (2008-02-01.version32) 54

Denture-Related Surgery

The following denture-related surgical services for remodelling and recontouring oral tissues are covered:

(1) remodelling, excision, removal, reduction, or augmentation of the alveolar bone.

(2) remodelling of the floor of the mouth.

(3) vestibuloplasty.

(4) reconstruction of the alveolar ridge.

(5) extensions of mucous folds.

(6) related surgical grafts.

Related stents, although not listed with denture-related surgery in the Canadian Dental Association Uniform System of Coding and List of Services, are also covered under this provision.

Appliance Maintenance

The following services are covered after the 3-month post-insertion care period has elapsed:

(1) denture remakes, once every 3 years.

(2) tissue conditioning.

(3) repairs to covered bridgework.

(4) removal and recementation of bridgework.

ORTHODONTIC COVERAGE

Orthodontics are covered for both children and adults. Children must be 6 years of age or over when treatment starts.

Diagnostic Services

The following diagnostic services are covered:

(1) orthodontic examinations.

(2) cephalometric radiographs.

(3) hand and wrist radiographs.

(4) diagnostic photographs.

(5) orthodontic diagnostic casts.

(6) consultation with Member of Profession.

Treatment

Fixed and removable appliances for orthodontic treatment are covered. This includes related charges for observations, adjustments, repairs, alterations, removal, and retention.


325156-B1 (2008-02-01.version32) 55

Benefit maximum

The maximum amount payable for orthodontics in each covered person’s lifetime is shown in the summary of coverages.

F. GENERAL LIMITATIONS



(2) services or supplies the person is entitled to without charge by law or for which a charge is made only because the person has coverage.

(3) services or supplies that do not represent reasonable treatment.

(4) services or supplies associated with treatment performed for cosmetic purposes only.

(5) services or supplies associated with congenital defects or developmental malformations in people 19 years of age or over except orthodontics.

(6) services or supplies associated with temporomandibular joint disorders.

(7) services or supplies associated with vertical dimension correction.

(8) services or supplies associated with myofacial pain.


(10) services or supplies covered under this contract's health care coverage, unless the amount payable for the same expenses is greater under this coverage. If it is, benefits will be paid under this coverage and not under the health care coverage.

A general limitation does not apply to coverage provided under this coverage that directly and specifically conflicts with that limitation. Where coverage is described only in general terms, a conflict is not considered to exist.

Late entrants limitation

If an individual enrolls for dental care coverage more than 31 days after first becoming eligible to do so, coverage during the first 12 months of coverage is limited to basic coverage to a maximum benefit of $100 per covered person. No benefits will be paid for major treatment during the first 12 months of coverage. No benefits are payable for orthodontic treatment during the first 24 months of coverage.

G. EXTENSION OF COVERAGE ON YOUR DEATH

If your dependents are covered under this coverage on the date of your death their dental care coverage will continue to the earlier of:

(1) the date they cease to be qualified dependents; or

(2) 24 months after your death.

If your child is born after your death, the child is considered a qualified dependent.


325156-B1 (2008-02-01.version32) 56

Survivor benefits are paid to the surviving spouse. If there is no surviving spouse, benefits are paid as follows:

(1) for a child who has reached the age of majority, to him; and

(2) for a minor child, to his legal guardian.

H. CLAIMS

Dental care benefits will only be paid for expenses for which Great-West Life has received satisfactory proof that payment is due. Proof must include pre-treatment radiographs and study models when required by Great-West Life.

Great-West Life will not be liable for expenses that are submitted more than 365 days after the end of the calendar year in which the expense was incurred.

Dental care benefits will be issued to the covered person unless:

(1) the covered person chooses to assign benefits to the provider of the service; and

(2) assignments to the provider of service are acceptable according to Great-West Life’s administrative practices at the time of claim.

Great-West Life has the right to conduct necessary investigations relating to applications or claims, and to obtain independent dental assessments if required. Great-West Life must also be given the opportunity to examine the person for whom an application or claim is made as often as it may reasonably require during the course of an investigation or assessment.

Great-West Life will not assume the cost of assessment or investigation in connection with a late application. Great-West Life may assume the cost of other assessments or investigations according to its administrative practices at the time of application or claim.

Part III. Preferred vision services (PVS)

325156-B1 (2008-02-01.version32) 57

PART III. PREFERRED VISION SERVICES (PVS)


Preferred Vision Services (PVS) is a service provided by Great-West Life to its customers through PVS which is a preferred provider network company. It does not form part of the contract issued to the Contractholder by Great-West Life.

PVS entitles you to a discount on a wide selection of quality eyewear and lens extras (scratch guarding, tints, etc.) when you purchase these items from a PVS network optician or optometrist. A discount on laser eye surgery can be obtained through an organization that is part of the PVS network.

PVS also entitles you to a discount on hearing aids (batteries, tubing, ear molds, etc.) when you purchase these items from a PVS network.

You are eligible to receive the PVS discount through the network whether or not you are enrolled for the extended health care coverage described in this group benefit plan. You can use the PVS network as often as you wish for yourself and your qualified dependents.

Using PVS:

(1) Call the PVS Information Hotline at 1-800-668-6444 or visit the PVS web site at www.pvs.ca for information about PVS locations and the program.

(2) Arrange for a fitting, an eye examination, a hearing assessment or a hearing test, if needed.

(3) Present your group benefit plan identification card, to identify your preferred status as a PVS member through Great-West Life, at the time the eyewear or the hearing aid is purchased, or at the initial consultation for laser eye surgery.

(4) Pay the reduced PVS price. If you have vision care coverage or hearing aid coverage for the product or service, obtain a receipt and submit it with a claim form to your insurance carrier in the usual manner.

325156 b1 active and retired post 6.6.00 · You should know 325156-B1 (2008-02-01.version32) 1 YOU...

Documents

Transcript of 325156 b1 active and retired post 6.6.00 · You should know 325156-B1 (2008-02-01.version32) 1 YOU...