PWU Benefits Booklet-Vertex

8/2/2019 PWU Benefits Booklet-Vertex

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GROUPBENEFIT

PLAN

VERTEX CUSTOMER

MANAGEMENT (CANADA) LTD.

Power Workers Union employees


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Health and Dental Plan

PWU (Effective October 1, 2007)

While your provincial health insurance plan covers basic medical care and hospital accommodation,

you and your family may have many other important health needs. These can range from regular

dental checkups or the occasional prescription drug to specialized services for a serious health

condition.

To help you meet these needs, Vertex Customer Management (Canada) Limited provides a

comprehensive program of health and dental benefits. For regular and probationary employees,

Vertex Customer Management (Canada) Limited pays the full cost of this coverage.

OurHospital Benefits plan covers the extra cost of a semi-private or private room in an active-treatment hospital and also helps pay for convalescent and chronic care accommodation.

With a convenient pay-direct drug card, ourPrescription Drug Benefit plan covers most drugs and

certain other products obtained on a doctors prescription.

TheExtended Health Benefits plan assists with a wide range of supplies and services, includingvision care, hearing aids, various health professionals and many kinds of medical devices and

equipment.

If you travel outside Ontario ourOut-of-ProvinceHealth Coverage includes financial assistance and

referral services in case of a medical emergency anywhere in the world.

To help you and your family maintain good dental health, ourDental Plan provides benefits for

preventive and basic care, as well as major restoration and orthodontic services.

Your Benefits at a Glance..................................................................................................................3

General Information ........................................................................................................................... 3

Semi-Private and Private Hospital Rooms.....................................................................................10

Prescription Drug Plan ....................................................................................................................10

Extended Health Benefits Plan .......................................................................................................13

Out-of-Province Health Coverage...................................................................................................19

Dental Benefits: Class A & B Services........................................................................................... 22

Dental Benefits: Orthodontic Services ..........................................................................................24

List of Dental Codes and Procedures ............................................................................................26


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Your Benefits at a Glance

Benefit Plan Benefits Participation & Cost

Ontario HealthInsurance Plan (OHIP)

covers many basic medical andhospital expenses

Automatic

Vertex CustomerManagement (Canada)

Limited pays a payroll tax

Hospital Benefits covers the extra cost of a semi-privateor private hospital room

Automatic

Paid by Vertex CustomerManagement (Canada)Limited

Prescription DrugBenefits

covers eligible prescribed drugexpenses

Automatic


Extended HealthBenefits

vision care

paramedic services

...and more

covers eligible expenses Automatic


Out-of-ProvinceBenefits

assists in case of a medicalemergency

Automatic


Dental Benefits

basic care

prosthodontics

major restoration

orthodontics

covers 100% of most basicprocedures and 85% of many majorprocedures

Automatic


General Information

Overview

The Extended Health Benefits Plan provides eligible employees, pensioners, and their dependentscomprehensive medical services which are among the very best available. This includes various levels ofcoverage for hospitalization, drug products, dental services and many other extended health benefits. Theobjective of this Plan is to provide comprehensive coverage, in a managed way, to facilitate employees,pensioners, and their dependents in their recovery from illness or injury.


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This plan description provides a detailed outline of the products and services covered under these plans.There are, however, limitations to that coverage and you should be aware of these. There are alsoreasonable and customary limits applied by the carrier (The Great-West Life Assurance Company) inadministering these benefits. This plan description also provides illustrations of these limits. If you areuncertain of what these limitations are, you are encouraged to contact Great-West Life at the telephonenumbers provided below:

Local calls withinthe London area

(519) 435-6903

Long distancecalls

1-800-318-6098

The mailing address for claims is:

The Great-West Life Assurance CompanyLondon Benefit Payments255 Dufferin AvenueLondon, OntarioN6A 4K1

Great-West Lifes business hours for inquiries are from 8:00 am to 4:30 pm, Monday through Friday(excluding statutory holidays). Messages may be left after 4:30 pm and all calls will be returned thefollowing business day.

RESPONSIBILITIES

Employees and Pensioners

It is your responsibility to ensure that all claims are legitimate.

It is essential that you keep your personal information up to date. For example, if a spouse is added ordeleted from coverage, your spouse changes employers and/or insurance carriers, and the addition or

deletion of dependent children:

Employees & Pensioners should contact Human Resources at (905) 944-3354

The Great-West Life Assurance Company

Our claims services provider for health and dental coverage is the Great-West Life Assurance Company. Itis Great-West Lifes responsibility to ensure that all legitimate claims for benefits that are covered underthe contract are reimbursed in accordance with the contract.

WHO IS COVERED?

Employees

Probationary and regular employees, including employees receiving Long Term Disability benefits, areeligible for coverage immediately from their first day of work and all coverage ceases immediately upontermination.

Pensioners and Beneficiaries

Employees who retire without a break in service having had health and dental coverage will continue toreceive benefits during their retirement equivalent to the current benefits available to active employees.


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Deferred pensioners will be eligible for these benefits upon retirement providing they had them asemployees and had a minimum of 25 years of continuous service with the Company prior to theirtermination date.

Eligible pensioners are entitled to the current health and dental benefits on the same basis as the employeegroup they belonged to at time of retirement.

Eligible beneficiaries are entitled to the current health and dental benefits on the same basis as the

employee group the pension plan member belonged to prior to death or retirement.

QUALIFIED DEPENDENTS

An employees spouse and dependent children as defined below.

Qualified Dependent Spouse

A spouse who is:

(1)the person legally married to the employee, or

(2)a person who is publicly represented by the employee as his or her spouse (including same sex

spouse).Only one person shall be considered a qualified dependent spouse during a period of time for which anybenefits are payable to or for the spouse of an employee.

In the event that an employee takes up residence with an individual and publicly represents that individualas his or her spouse, the spouse status of any other individual shall automatically terminate. An individualwho fails or ceases to meet the criteria specified in item (1) or (2) above shall immediately be renderedineligible as a qualified dependent spouse.

If you and your spouse are both employed by Vertex Customer Management (Canada) Limited and areboth eligible for health and dental benefits through Vertex Customer Management (Canada) Limited, oneemployee is designated as the subscriber and the other employee is designated as the dependent

spouse.

Make sure you keep Human Resources informed of any change in your family status.

Qualified Dependent Children

An unmarried child (of an employee or an employees spouse) including legally adopted who isunmarried, unemployed, attending school full-time, up to and including 23 years of age. Coverage fordependent children ceases as of their 24th birthday.

A child to whom the employee stands in the position of a parent for Income Tax purposes. That is thechild must be:

A niece, nephew, or grandchild of the employee or spouse,

A resident in Canada and living with the employee,

Wholly dependent for support (e.g. food and shelter) on the employee or spouse,

Receiving a personal income of less than the basic personal amount allowable under the income taxact per year, and

Under age 19.


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A child ofany age (of an employee or an employees spouse) who is dependent for financial supportupon the employee or the employees spouse because of a physical or mental infirmity, provided thechild had the infirmity while eligible for coverage under the above criteria.

Coverage will continue for as long as the child remains continuously dependent for financialsupport upon the employee or the employees spouse because of said physical or mental infirmity.

Vertex Customer Management (Canada) Limited will determine the eligibility of physically ormentally infirm dependent children as qualified dependents and furnish written proof withinstructions for Great-West Life to continue coverage.

Definitions

Calendar Year

A period of time commencing January 1 and ending December 31 or any other shorter period of timefalling between those dates, during which the Plan is in force.

Licensed Practitioner

Includes a duly licensed medical doctor, dentist, physiotherapist, nurse practitioner, audiologist,optometrist, clinical psychologist, speech therapist, chiropractor, podiatrist, or chiropodist, who is licensed,certified, registered or qualified by the jurisdiction in which the person is practicing within the scope of hisor her profession.

Only medical doctors, dentists, podiatrists, chiropodists, and nurse practitioners can prescribe drugs.

Effective Date

The date on which the coverage under the Plan becomes effective for an employee or qualified dependent.

Hospital

An institution accredited as a hospital by the Canadian Council on Hospital Accreditation or approved for

resident in-patient care under a provincial hospital services program. However, it does not include asanatorium, a mental hospital, a nursing home, a chronic care hospital, a chronic care unit in a publicgeneral hospital, or a facility for the care of the aged; or an institution operated primarily as a school, orwhose primary function is to furnish domiciliary or custodial care; or hospitals outside of Canada.

Registered Nurse

A person who is registered as a nurse under the Health Disciplines Act or licensed in the jurisdiction inwhich her or his professional services are rendered to the employee or dependent to provide servicesequivalent to those which are provided by registered nurses in Ontario.

In this plan description, the term Employee includes Pensioners and Beneficiaries unless

otherwise specified.

Process for Submitting Claims

Employees may print Claim Forms from the web under Forms Cabinet. Pensioners will receive a newclaim form upon receipt of payment by the carrier for a previous claim. The mailing address is on theclaim form.

If you have both a health and a dental claim use two forms, because the health claim is forwarded to thehealth unit and the dental claim is forwarded to the dental unit for payment.


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Make sure you provide all the details requested on the claim form to ensure prompt processing.

When submitting your health or dental claim to the Great-West Life Assurance Company, remember tocomplete the Claim Form in its entirety.

To ensure prompt processing of your health claim for all eligible medical devices and supplies, includewritten documentation from the medical practitioner detailing the patients condition and the medical

necessity for the device or equipment. This will speed up reimbursement of your claim as Great-West Lifewill not have to ask you for additional information.

For goods and services requiring a prescription, the prescription must be obtained before the goods arepurchased.

Right of Recovery

If at any time payments have been made by Great-West Life and such payments are in excess of theeligible amount, Great-West Life shall have the right to recover such payments, to the extent of suchexcess, from any persons to or with respect to whom such payments were made, any insurance companies,and any other organizations.

Co-ordination of Benefits

Employees and pensioners whose spouses have health and/or dental coverage through another employermust co-ordinate their claims through the two insurance plans. This enables couples to maximize themoney they get back related to their claims and the Company saves money.

Co-ordination of benefits ensures that you get as much reimbursement as possible from both

plans combined in a manner that is consistent and fair.

The spouse submits his/her claims to his/her insurance company first. If the full amount of the claim hasnot been covered, the remainder can then be submitted under Vertex Customer Management (Canada)

Limiteds plan up to its maximum.Similarly, when claims are submitted to Vertex Customer Management (Canada) Limiteds plan and thefull claim is not covered, the unpaid portion can be submitted to the spouses plan for all, or part of, theamount not covered by our plan.

The spouse whose birth date is the earliest in the year (regardless of age) must claim the dependentchildren on his/her plan first. Any unpaid portion can later be claimed on the other spouses plan followinginitial reimbursement.

Right to Receive and Release Necessary Information

For the purposes of determining the applicability of this plans co-ordination of benefits provision and

implementing its terms or those of any provision of similar Plans, Great-West Life, without the consent of,or notice to, any person, may release to or obtain from any insurance company, organization, or person anyinformation, with respect to any person, which Great-West Life deems to be necessary for such purposes.Any person claiming benefits under this Plan shall furnish to Great-West Life such information as may benecessary to implement this provision.

Annual Deductible (effective October 1, 2007)

The deductible for the Extended Health Benefits Plan is:


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$10.00 per calendar year for a single subscriber and

$20.00 per calendar year for families.

The annual deductible applies to the types of expenses indicated below. You pay only one deductible forall of types of benefits combined.

Type of Expense Deductible Applies

Private Hospital Room Yes

Semi-Private HospitalRoom

No

Prescription Drugs Yes

Vision Care No

Hearing Aids No

Other Extended HealthBenefits

Yes

Out-of-ProvinceBenefits

No

Dental Care No

Expenses incurred during the months of October, November and December may be carried over to thefollowing calendar year and applied toward the deductible in that year.

Reasonable and Customary Services

To be considered reasonably necessary, the medical services or products must be ordered by a physician

and must be commonly and customarily recognized throughout the physicians profession as appropriate inthe treatment of the patients diagnosed sickness, injury or condition.

These plans will pay the excess over the deductible portion of the reasonable and customary charges andtime limitations for the services and supplies set out in this plan description, when necessary for the careand treatment of injury or illness and when ordered or prescribed by a licensed medical practitioner.

The reasonable and customary charge of any service or supply is the usual charge of a similar provider inthe area. Asimilar service is one of the same nature and duration, requires the same skill, and is performedby a provider of similar training and experience.Area means the town or city in which the service orsupply is actually provided within Ontario.

Reasonable and customary applies to all benefits. Examples are provided throughout the plan

description.

Payment on Foreign Exchange Rate

All monies payable under the Plan will be paid in Canadian dollars. For claims incurred outside Ontario,the foreign exchange rate will be the rate in effect on the date the charges for services are paid by theemployee in the foreign country.


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Excluded Charges

The following medical services and supplies are not covered by the Extended Health Benefits Plan.

Services or supplies normally paid through any provincial hospital plan, provincial medical plan,Workplace Safety & Insurance Board (WSIB), other government agencies or any other source.

Charges for unnecessary services and supplies for medical care of the patients sickness, injury, orcondition.

Coverage for the treatment of tuberculosis and mental illness when the patient is confined to a specialinstitution for such treatment.

Rest cures, travel for health reasons or insurance examinations.

The portion of any charge, for any service or supply, in excess of the reasonable and customary charge.

Any charge, or service, which exceeds the amount which would normally be paid in Ontario.

For benefits items which may be eligible for coverage under the WSIB and/or the Assistive DevicesProgram, as well as the Vertex Customer Management (Canada) Limited Extended Health Benefits(EHB) Plan, employees can claim the difference between what they actually pay and the amount

reimbursed by the government agency.

Example

A hearing aid costs $800.00

Assistive DevicesProgram covers

$500.00

Great-West Life willreimburse

$300.00

Tax Information

You do not pay income tax on Vertex Customer Management (Canada) Limiteds cost of providingyou with Health and Dental plan benefits

If any of your health and dental expenses are not fully reimbursed by the Vertex CustomerManagement (Canada) Limited plans or any other plan, you may claim the remaining amount as amedical expense for income tax purposes.

The benefits paid to you for health and dental claims are not subject to income tax.


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Semi-Private and Private Hospital Rooms

Semi-Private Hospital Rooms

The Semi-Private Hospital Plan covers:

The semi-private differential between ward accommodation (covered by Ontario Health Insurance Plan(OHIP)) and semi-private accommodation in an active treatment hospital, such as Toronto Hospital(this also includes the Shouldice Clinic).

Up to $40.00 per day for a maximum of 120 days in any period of 365 consecutive days, towardssemi-private or private room accommodation in a hospital for the chronically ill or a chronic care unitof a general hospital.

Up to $20.00 per day towards semi-private or private room accommodation (ward is covered by theOntario Health Insurance Plan (OHIP)) in a convalescent or rehabilitative hospital, such as St. Johnsin Toronto, up to a maximum of 365 days per lifetime.

Private Hospital Rooms

The Extended Health Benefits Plan covers the differential between semi-private and private roomaccommodation (but not a suite) in an active treatment hospital.

The private room does not require a physicians authorization.

Note: this item is subject to the annual deductible.

Prescription Drug Plan

Vertex Customer Management (Canada) Limited Drug Formulary

This plan covers drugs that are listed on a drug formulary. This is simply a list of approved drugs.

Eligible Drugs

Drugs listed in the Vertex Customer Management (Canada) Limited Drug Formulary are coveredwhen purchased on the prescription of a licensed medical practitioner.

Vitamins B12 and B6 are excluded when used in conjunction with weight loss treatment.

Employees are eligible for drugs for the current month, plus an additional two months, for a maximum ofthree months supply.

Pensioners are eligible for the current month, plus an additional seven months, for a maximum ofeightmonths supply.

Dispensing Fee Drugs that Require a Prescription by Law

Adispensing fee is the amount charged by the pharmacy for filling your prescription. It is separate fromthe cost of the ingredients.

You are encouraged to shop around for pharmacies that have lower dispensing fees and still

provide the level of service you need.


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Generic Substitution and Excess Charges

For all brand name drugs that have a generic substitute, only the generic substitute will be fully paidfor, unless the doctor handwrites no substitutes on the prescription. If you demand a brand nameproduct, you will have to pay the amount in excess of the price for the generic substitute at your ownexpense.

Dispensing Fee Drugs that do not Require a Prescription by LawOver-the-counter drugs that do not require a prescription by law will be covered if they are on the VertexCustomer Management (Canada) Limited Drug Formulary and are medically required for the treatment ofan illness, injury or condition (that is, when prescribed by a doctor). The doctor should be asked to writeout the information pertaining to over-the-counter products, separate from the drugs requiring aprescription by law. (See Option Two below.)

There are two options for claiming the cost of over-the-counter products:

Option One Mandatory - Dispensed by Pharmacist:

Present your benefits card to the Pharmacist and they can electronically submit your claim to AssureHealth Inc. The Pharmacist will be reimbursed up to a maximum dispensing fee equivalent to thedispensing fee set for the Ontario Drug Benefit (ODB) Plan (currently $6.11 per prescription). If thePharmacist demands payment of a dispensing fee in excess of $6.11, you will have to (1) pay the excessamount, or (2) go to another Pharmacist who will agree to a dispensing fee at, or below, the ODBdispensing fee for over-the-counter products.

Option Two Cash Register Receipt:

You can only submit this type of claim twice per year in April and October (this limit does not apply topaper claims for co-ordination of benefits).

You can manually submit the original copy of the prescription, along with the sales receipt, to Great-WestLife for reimbursement. However, submissions for over-the-counter items will need to be accompanied by

a separate prescription, and not combined with those requiring a prescription by law.Great-West Life must be able to readily identify the specific item on the sales receipt correspondingto the specific over-the-counter prescription in order to process the claim for the price of the over-the-counter product, plus the applicable sales tax. If the cash register receipt does not identify specific items,then the clerk should be asked to handwrite the name and drug identification number of the product andinitial the sales receipt.

In the case of repeat over-the-counter prescribed drugs, you should attach a photocopy of the originaldoctors prescription previously submitted to Great-West Life. If a photocopy is not available, you shouldadvise Great-West Life that this is a repeat prescription when the original doctors prescription issubmitted with the first claim.

NOTE: Option One is preferable for you and Vertex Customer Management (Canada) Limited. Itshould be used whenever possible as it is more efficient, no sales tax is charged, no additionaladministration fee is charged, and there is no additional up-front, out-of-pocket, payment requiredon your part.

For drug claims submitted electronically through Assure Health Inc., there will be no delay in payment.However, if the receipt is submitted on a paper claim it will need to be processed by Great-West Lifethrough Assure Health Inc. and therefore will normally take 7 to 10 days longer to process than claimsprocessed electronically through Assure Health Inc.


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Always bring your Benefits Card along when having a prescription filled.

If you are currently submitting claims for drugs to Great-West Life by mail, you are encouraged to askyour Pharmacist if your drug claims can be processed electronically through Assure Health Inc. AssureHealth Inc. is a company that electronically processes drug claims for the Great-West Life AssuranceCompany and other insurance carriers. Present your benefits card to the Pharmacist and they will inputyour name, employee number, Vertex Customer Management (Canada) Limiteds policy number, the DrugIdentification Number (DIN), and the cost, for reimbursement. The majority of pharmacies in Ontario havethis capability. Assure Health Inc. is more efficient and requires no up-front, out-of-pocket, payment fromthe employee, subject to the limits set out above.

When purchasing a drug using your Benefits Card, please be sure to give your Pharmacist the

relationship of the patient (employee/pensioner, spouse, or child) and the patients accurate dateof birth. If this information is not accurate, your claim will be rejected and the card will not

work.

Reasonable and Customary Limitations

The following are some reasonable and customary limitations under the Drug Plan. These limits arereviewed annually in light of current community practices.

Prescription Drugs

Reimbursement to pharmacists for the cost of drugs is normally wholesale price + 10% (plus thedispensing fee if appropriate). This is generally referred to as Best Available Price (BAP). The pharmaciesunderstand this method of pricing as it is a common community practice and pharmacies tend to limit theircharges to align with this procedure.

Smoking Cessation Products

Smoking cessation products on the Vertex Customer Management (Canada) Limited Drug Formulary, suchas nicorette gum, nicotine patch, or zyban, are covered when prescribed by a physician, up to $1,000 perperson per year.

Fertility Drugs

Fertility drugs on the Vertex Customer Management (Canada) Limited Drug Formulary are covered whenprescribed by a physician for up to 12 months, or to a maximum cost of $5,000 per lifetime, whichevercomes first. In vitro fertilization (IVF) and related drugs are not covered.

Food Supplements

Food supplements are not covered; except for:

Nutramigen or like product, for very sick children, when prescribed by a physician, and

Ensure or like product for very sick adults, when prescribed by a physician.

Should you have any questions concerning eligible drugs, you can search the Vertex CustomerManagement (Canada) Limited Drug Formulary on the Web under Human Resources, Employee Benefitsor telephone Great-West Life directly.


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Ontario Drug Benefit (ODB) Plan Co-ordination with Vertex Customer Management (Canada)Limited Plan

Pensioners living in Ontario who are age 65 and older are covered under the Ontario Drug Benefit (ODB)Plan. If you and/or your dependents are eligible for the Vertex Customer Management (Canada) LimitedExtended Health Benefits Plan you are required to pay the first $100 per year of the ODB Plan. You willalso be asked to pay the dispensing fee thereafter. Such payments may be claimed through Great-WestLife for reimbursement.

Pensioners living outside Ontario who are age 65 or older and eligible for Vertex Customer Management(Canada) Limited drug benefits are also entitled to receive the first $100 per year and the payment fordispensing fees up to $6.11 for drugs normally covered by the ODB Plan. These pensioners should attachtheir receipts to a Health Claim Form and mail them to the Great-West Life Assurance Company. Great-West Life will not pay the costs of any drugs normally covered by the ODB Plan.

Extended Health Benefits PlanThe Extended Health Benefits Plan includes the following benefits:

Vision Care

Effective October 1, 2007 Eyeglasses, Contact Lenses and Repairs are coveredup to a total amount of$450.00 per person in a two-calendar year period, when provided on the written prescription of a medicaldoctor or optometrist for corrective lenses. Effective October 1, 2009 the coverage will increase to$475.00 per person.

The current two-year calendar period for vision care expenses commenced January 1, 2008.

Prescription sunglasses are eligible under this Plan. Sunglasses, eyeglasses for cosmetic purposes, andrecreational eyewear (e.g. diving masks, goggles, etc.) are not covered.

Claims should not be submitted to Great-West Life until the eyeglasses/contact lenses have been paid forin full and a receipt for full payment can be supplied to Great-West Life. The date of the final bill is theeffective date of your claim.

Radial Kerototomy and Laser Keratectomy are covered up to a maximum of$3000.00 per person perlifetime.

Eye examinations for employees and qualified dependents over age 19 but younger than 65 are coveredonce every calendar year. Eye examinations for employees and qualified dependents under age 20 and age65 and over are covered by OHIP.

By calling Preferred Vision Services (PVS) at 1-800-668-6444, or connecting to the website athttp://www.pvs.ca , you can receive up to a 20% discount on your frames, lenses, and/or contact lenses just

by showing your Vertex Customer Management (Canada) Limited Benefits Card before you make yourpurchase. PVS will direct you to the preferred carriers closest to you for your convenience.

Physiotherapy Treatments

If the physiotherapist is not registered with OHIP, Great-West Life will reimburse the entire cost fortreatments up to the reasonable and customary limits. If the physiotherapist has an agreement with OHIP,Great West Life will reimburse additional charges above those covered by OHIP, up to reasonable andcustomary limits.
http://www.pvs.ca/http://www.pvs.ca/


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The physiotherapist cannot be a member of your family or related to a member of your family.

Some examples of reasonable and customary limits for a Registered Physiotherapists are:

Assessments Maximum of $100 perassessment.

Treatments Maximum of $60 per treatment

SynviscInjections (or like products)

For treatment of Osteoarthritis are covered up to a lifetime maximum of$3,000.00 per person.

Chiropractors

Chiropractic charges (including X-rays) in excess of OHIP coverage will be paid on a per visit basis upto $800.00 maximum per person per calendar year.

Where an eligible individual is provided with the services of a duly licensed chiropractor, the claimsprovider will pay those charges, including charges for X-rays, in excess of what OHIP allows or pays, upto the Chiropractic limit set out above.

Podiatrists and Chiropodists

Podiatrists and Chiropodists charges in excess of OHIP coverage will be paid to a maximum of$200.00per person per calendar year.

Other Paramedical Services

Naturopaths, Osteopaths, Clinical Ecologists, Homeopaths, Acupuncturists, Reflexologists, and RegisteredMasseurs are covered on a per visit basis up to an aggregate maximum of$600.00 per person percalendar year based on 50% co-insurance.

For example, if you submit a claim for $300.00, you will receive $150.00. If the claim is for $1,200.00,

you will receive $600.00 (the maximum). Reimbursement is based on the date on which the treatment wasadministered by the medical practitioner.

Registered Clinical Psychologists

Charges for the services of a Registered Clinical Psychologist will be paid up to a maximum of$2,000.00per person per calendar year.

In order to secure benefits for the eligible psychological services, the patient must obtain a fully itemizedreceipt signed by the registered psychologist indicating the dates of the service and the amount charged foreach service.

Psychologists fees are normally only paid when the services are provided by a clinical psychologist.However, this benefit will also include payment for psychological training courses, where recommendedfor families of chronically ill patients (e.g. where the patient is dying), even if such training is not providedby a registered clinical psychologist, so long as such courses are recommended by a physician or registeredclinical psychologist.

Some of the reasonable and customary conditions which apply include:

Learning Disabilities some charges are covered for initial testing, but no coverage for reports.


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Aptitude Testing is not covered, as it is not treating an illness, injury, or medical condition. Reportsin general are not covered.

Speech Therapists

Effective October 1, 2004 charges for the services of qualified Speech Therapists will be paid up to$300.00 per person per calendar year, only when the patients attending physician or dentist authorizes in

writing that such treatment is necessary.

Hearing Aids

Hearing aids (including ear moulds and batteries with initial purchase only) are covered on the writtenprescription of an audiologist, or a hearing aid specialist authorized with the Ontario GovernmentsAssistive Devices Program (ADP), once in any period of three consecutive calendar years. This caninclude purchase or repairs.

Hearing tests are covered at 100%.

Reasonable and customary costs will be reimbursed

NOTE: The ADP covers a portion of the costs, for both ears, once every three years. Great-West Life willreimburse the outstanding balance.

TENS Units

TENS (Transcutaneous Electronic Nerve Stimulator) Units, including associated supplies, are covered on areasonable and customary basis when prescribed by a physician once per person every three years.

Wigs

Wigs (one every three calendar years) for cancer patients receiving chemotherapy or radiation treatment,burn patients and patients with alopecia are covered. This does not include hair care products or drycleaning.

The reasonable and customary limit for wigs for cancer patients, when prescribed by a physician is up to$500.

Liquid Meals

Liquid meals for cancer patients receiving chemotherapy or radiation treatment are covered.

Incontinence Products

Incontinence products for cancer patients will be covered.

Blood Pressure KitsOne every three calendar years when prescribed by a physician.

Blood and Blood Products

Blood and blood products for transfusions are covered. On the prescription of the attending physician,Great-West Life will pay the customary charge, where reasonable, to the extent to which such service isnot paid for or provided by a government department or agency (e.g. OHIP, WSIB).


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Laboratory Tests

Laboratory tests by a qualified person are covered by this plan when not covered by any governmentagency.

Includes payment for an annual PSA blood test (to detect prostate cancer).

Where an eligible individual receives diagnostic services in a hospital or laboratory, authorized by aphysician, Great-West Life will pay for such diagnostic services to the extent they are not paid by OHIP.

LymphaPress Pump

ALympha Press Pumpand associated equipment are covered for rental or purchase, when medicallydocumented that the patient has lymphedema and has been unresponsive to other types of therapy. Theassociated equipment includes pumps, pump sleeves, gauntlets and graduated compression sleeves.

Radium and Radioactive Isotope Treatments

Radium and radioactive isotope treatments are covered when authorized in writing by the patientsattending physician.

Great-West Life will pay the reasonable and customary charge when such service is not provided by agovernment department or agency (e.g. WSIB or OHIP).

Custom-made Boots or Shoes

Purchase of custom-made boots or shoes or the cost of adjustments to stock item footwear are covered to amaximum of two pairs per calendar year, prescribed by a podiatrist, chiropodist, orthopedic surgeon, orgeneral medical practitioner.

Great-West Life will pay the reasonable and customary charges.

Ready-made extra depth orthopedic shoes are only covered when medically required and prescribed by alicensed practitioner to treat a skeletal deformity, specifically hammer toes or clawfoot. They are not

covered to accommodate orthotics or extra wide feet. Other items not covered include orthopedic winterboots, sandals, and comfort shoes such as Reebok, Nike, Rockport, or Mephisto.

Orthotics

Orthotics (arch supports) prescribed by a podiatrist, chiropodist, chiropractor, orthopedic surgeon, orgeneral medical practitioner, are covered for one pair of hard or regular orthotics (including semi-rigid)every three calendar years up to a maximum of$375.00.

Soft orthotics (leather or cork), sport orthotics, or fashion orthotics are not covered. However, softorthotics will be considered if the individual has a medical condition preventing the wearing of hardorthotics, if supported by justification from the licensed practitioner.

NOTE: As childrens feet grow, reimbursement may be made for up to $375.00 per year until age 18.

Respiratory Devices

Respiratory devices such as aero chambers, nebulizers, compressors, CPAP machine and relatedsupplies, prescribed by a physician are covered for the reasonable and customary amount above which theAssistive Devices Program (ADP) pays. If ADP does not cover a respiratory device, Great-West Life willprovide full reimbursement up to the reasonable and customary amount providing the item is the leastcostly to satisfy the medical necessity.


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NOTE: If a patient is reimbursed for an aero chamber and later requires a compressor, and it qualifiesunder the ADP, the amount paid for the aero chamber will be deducted from the cost of the compressor.

Diabetic Supplies

Most diabetic supplies are covered, including needles and syringes, dextrosticks, glucosticks, autolets,autoclicks, lancets, Preci-jet guns, insulin pumps and necessary hardware, and blood glucose meter

(glucometer).Note: a patient does not need to be insulin dependent to be eligible for a blood glucose meter.

Replacement of a blood glucose meter, Preci-jet gun, insulin pump and necessary hardware, are eligibleonce every three calendar years.

Therapeutic Equipment

Eligible items include:

prosthetic appliances, crutches, splints, casts, trusses, braces;

oxygen and rental of equipment for administration thereof;

rental of wheel chairs, respirators and manual hospital-type beds.

Consideration may be given to claims for purchase or repair of such articles.

To check whether a particular expense will be covered, please contact Great-West Life.

Where an eligible person, on the basis of a written report or prescription from the attending physician,requires the following items, Great-West Life will pay the reasonable and customary charges for sucharticles:

an artificial limb or eye, cervical collars, cervical pillows (maximum of one per person per calendar year),

braces,

catheters, urinary kits,

external breast prosthesis following mastectomies (the additional 25% not covered by the AssistiveDevices Program (ADP), once every two years, and up to three brassieres per year),

ostomy supplies (where a surgical stoma exists).

A lumbo-sacral support belt qualifies as a back brace. The regular Obus Form back support and similar

back supports are covered if prescribed by an orthopedic surgeon or chiropractor (but not a generalpractitioner), up to one per individual, once every five years. The maxi and mini Obus Form back supportsare not covered and the seat support is not covered.

Support stockings, such as Jobst or Sigvarius, are covered. An eligible individual may claim a maximumof three pairs per year. The less expensive support stockings, readily available without a prescription, arenot covered.

Where an eligible person, on the written advice of the attending physician, requires the following items fortherapeutic use, Great-West Life will pay a reasonable rental or other charge:


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wheelchair (electric wheelchairs are excluded unless a certified orthopedic specialist recommends apower-driven unit because of a medical necessity),

manual hospital bed (electric hospital bed will be paid up to the cost of a manual bed), crutches,cane, walker,

oxygen set and respirator,

provided, however, in cases where the eligible person is entitled to have the above equipment provided orthe rental charges or cost thereof paid for by a government department or agency (e.g. WSIB, OHIP), thePlan shall incur no liability under this clause. The decision to rent or purchase shall be made by Great-West Life and shall be based on the Physicians estimate of the duration of need, but in any event Great-West Life will not pay rental charges in excess of the purchase price. Consideration may be given to therepair of the articles listed above when considered reasonable by Great-West Life.

The following items are not covered:

pacemakers, morphine pumps, circulatory pumps

ortho pac bone growth stimulators

bathtub bars/hand rails, commode chairs electronic air cleaners, central/home air conditioners

water beds, craftomatic beds

hot tubs

exercise equipment

chair lifts, access ramps

Private Duty Nursing

Private duty nursing by a Registered Nurse who is registered in any of the provinces of Canada (not arelative) is covered, either in the hospital or home, providing it is ordered by the attending physician, toan annual maximum of $50,000 and a lifetime maximum of $150,000. Custodial care, agency fees, orshift/overtime premiums are not covered.

The maximum fee paid is the level set by the largest Nursing Registry in the Province of Ontario.

This plan does not cover services which:

are mainly custodial;

are mainly to assist with the functions of daily living or to dispense oral medication; or

could be provided by someone who does not have the professional qualifications of a Registered

Nurse.

Ambulance Service

Ambulance services are covered for the portion not covered by any government agency.

Professional ambulance service will be paid to the nearest facility in Ontario competent to care for theindividual when the service is paid for in part by a government plan or agency (e.g. OHIP). This alsoincludes air ambulance, when necessary.


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Dental Treatment due to an Accident

Dental treatment is covered for the restoration of the area damaged as the result of an accident whichhappens while the plan is in effect, but not for repair or replacement of artificial teeth.

Treatment must commence within 90 days of the accident. The plan will not pay for any charges fortreatment performed after the 365th day following the accident or after termination of your coverage,whichever is the earliest.

Some items are subject to specific conditions not mentioned here. Where possible, you are

advised to contact Great-West Life in advanceto check whether a certain item or service is

covered and whether any limitations or special conditions apply.

Out-of-Province Health Coverage

PWU employees and pensioners (including eligible dependents) who retired as PWU represented staff arecovered for the regular semi-private hospital accommodation and Extended Health Benefits (EHB) whentravelling outside their province of residence.

This coverage does not apply during work assignments for other companies.

Benefits Coverage

The following benefits with Global Medical Assistance described may be covered, for an emergencyillness or injury (only) which occurs while travelling outside your Province of Residence. After theemergency is dealt with, such additional coverage ceases. On-going medical care, even for theincident/situation that began as an emergency, is not covered by these additional benefits.

Global Medical Assistance (GMA)

Through an arrangement with MEDEX Assistance Corporation, Global Medical Assistance providesworldwide assistance to travelers in emergency medical situations and obtains Great-West Lifes approvalfor covered medical expenses.

The Ontario Health Insurance Plan (OHIP) provides some protection outside Ontario, but it may not besufficient if you are faced with a medical emergency away from home.

You can contact a toll-free emergency hotline from anywhere in the world.

Global Medical Assistance provides benefits and services over and above the basics. It gives you access tomultilingual representatives who will direct you to the nearest, most appropriate physicians and healthcarefacilities and help you with travel arrangements.

This plan deals with emergency situations; it does not cover ongoing medical care after the initialemergency has been dealt with.

MEDEX Assistance Corporation

This coverage is provided for most destinations around the world. You have access to a direct telephonehotline 24 hours a day, every day. MEDEX can help you locate hospitals, clinics and physicians who canprovide appropriate medical care. If necessary, medical evacuation is arranged.


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Medical Advisors

Qualified licensed physicians, under agreement with MEDEX, provide consultative and advisory servicesas well as second opinions.

Courtesy Assistance

MEDEX can help you locate qualified legal assistance, local interpreters and appropriate services for

replacing lost passports.

Admission Advance Assistance

MEDEX will arrange an upfront deposit to a maximum of $1,000 if required for hospital confinement,with no minimum requirement.

Assisting Unattended Children

If you are hospitalized, MEDEX will assist your unattended children, in returning home by providingtransportation expenses, helping with travel arrangements, boarding and making connections. A qualifiedescort will accompany them, if necessary.

Return of Vehicle

If sickness, injury or death prevents you from driving, and there is no other driver available, GMA will payup to $1,000 toward the cost of a vehicle being returned home or to the nearest rental agency.

Medical Evacuation

If you experience a medical emergency while travelling and suitable local care is not available, GMAcovers the cost of a medical evacuation to the nearest adequate facility equipped to provide the requiredtreatment. You may be brought back to Canada if extensive treatment is needed and your medicalcondition permits transportation.

Transportation to Bedside

If you are hospitalized for more than seven days and have been travelling alone, GMA will cover theexpense of bringing one family member to the hospital. GMA covers the expense of one round-tripeconomy airfare, plus up to $1,500 Canadian in lodging expenses.

Travelling Companion Expenses

If you are confined to a hospital for more than 10 days, and have been travelling with a related companion,GMA will cover the cost of economy class transportation for your related companion to a permanent placeof residence. Meals and accommodation are not covered.

Note: For one emergency, you may use either Transportation to Bedside or Travelling CompanionExpenses, but not both benefits.

Transportation of Remains

In the event of death, expenses for preparing and transporting a travelers remains home are covered.MEDEX can help make the arrangements. Funeral expenses are not covered.


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Arranging for Assistance

In the event of a medical emergency, contact MEDEX using the following numbers:

In Canada or the United States call toll-free 1-800-527-0218

outside Canada or the United States call collect 1-410-453-6330.

MEDEX will help you arrange for appropriate medical care, verify your insurance coverage, and provide

necessary travel assistance, such as flight, hotel accommodation and vehicle return. If required, they canalso provide advance payments, subject to the approval of Great-West Life.

Always take your Benefits Card with you when you travel outside your province.

Hospital Bills

Hospitals do not accept your Benefits Card as proof of medical coverage. They will usually call MEDEX,which will then contact Great-West Life to verify your coverage. If for any reason the hospital will notcontact MEDEX, you or a family member should do so. MEDEX will then call the hospital directly andtake whatever measures are appropriate.

You are responsible for arranging payment for all hospital and doctor bills when you are discharged. In

some cases, hospitals may allow you to assign your insurance benefits to them in place of full payment.

Claims should be submitted as soon as possible after you return home.

Claims

When you return home, contact Great-West Life for the forms you need to submit a claim. Submit claimsdirectly to Great-West Life and include all your original receipts.

In most cases, Great-West Life will pay your provincial health plans share of the claim, on the provincesbehalf. Great-West Life will also reimburse you on the balance of expenses covered by your Extended HealthBenefits Plan.

We suggest you contact your provincial health plan (OHIP) prior to leaving the country to determine theextent of its coverage. Many provincial health plans have time limitations on the submission of claims.These time limits will apply to your Great-West claim as well. If your provincial health plan refusespayment, you may be asked to reimburse Great-West for any amount they have already paid on yourbehalf.

Your claims to Great-West should be sent to:

Great-West Life, Out-of-Country Claims DepartmentP.O. Box 6000Winnipeg, Manitoba

R3C 3A5

If you have any questions on your claim or coverage, call Great-West Life toll free at:1-800-957-9777 and ask for a client service representative in the out-of-country claims department.


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Dental Benefits:Class A & B Services

There is no annual maximum on the dental benefits.

Eligible Charges

Dental expenses are covered as shown below:

Dental Service Benefit

Class A Services: Preventiveand Basic RestorativeServices

covers 100% of the cost as setin the ODA fee guide forgeneral practitioners

Class B Services: MajorRestorative Services

covers 85% of the cost as set inthe ODA fee guide for generalpractitioners

List of Dental Services

This plan covers only those services listed under List of Dental Codes and Procedures provided at theend of this plan description (as designated by the ODA Suggested Fee Guide for General Practitioners).Any services not listed are excluded. Fees for specialists may be considered up to fee amount for a generalpractitioner if applicable.

If two or more services included in this list are separately suitable for the dental care of a specificcondition, according to customary dental practices, and if a charge is actually incurred for one of such

services, then a charge for only the least expensive of such services will be considered to have beenincurred.

The ODA Fee Guide Codes and related Procedures are set out in the List of Dental Codes and Procedures.

A charge is deemed to have been incurred on the date the service was completed.

Fee Guide

Eligible dental expenses are covered as indicated on the following list of dental codes and proceduresbased on the amount shown in the current years Ontario Dental Associations (ODA) Suggested FeeGuide for General Practitioners. The following exceptions apply:

Dental lab fees are covered up to 60% of the Ontario Dental Associations suggested amount forgeneral practitioners for the related dental procedure.

Services of denture therapists and denturists, including lab fees, are covered for 85% of the cost basedon the current Denture Therapists Fee Guide.


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Summary of Covered Expenses

The following is a summary of the most commonly-used Class A and Class B expenses included in theList of Dental Codes and Procedures. To check whether a specific item is covered, please refer to the Listor contact Great-West Life.

Class A - Preventive Services (100%)

regular checkups (once every 9 months) cleaning and polishing (once every 9 months)

x-rays (bitewing x-rays once every 9 months; panoramic and complete series once every three years)

fluoride treatment for children under age 19 (once every 9 months)

oral hygiene instruction

pit and fissure sealant to permanent molars for children under age 19 (once every three years)

Class A - Basic Restorative Services (100%)

fillings, extractions and minor oral surgery

anesthesia performed with oral surgery

endodontics (root canal work)

periodontics (gum treatment)

Class B - Major Restorative Services (85%)

crowns, caps, fixed bridgework

partial and complete dentures (once every 3 calendar years)

relining, rebasing and repair of dentures

Predetermination

For your protection, if the course of treatment involves charges of $600.00 or more, it is suggested that thetreatment plan should be submitted to Great-West Life in advance for predetermination of benefits. Great-West Life will advise you before treatment is started of the amount allowed by the plan. Predeterminationsare valid for a maximum of 6 months.

With a predetermination, you will know exactly what costs are covered before you have the work

done.

Limitations on Dental Benefits Provided Outside OntarioTreatment received outside the Province of Ontario is covered, but limited to the amount shown in theOntario Dental Associations Fee Guide for General Practitioners. Patientsshould obtain a completewritten description of the procedures for dental treatments performed outside Canada.

All moneys payable under the Plan will be paid in Canadian dollars. For claims incurred outside Ontario,the foreign exchange rate will be the rate in effect on the date the charges for services are paid by theemployee in the foreign country.


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Charges Not Covered

The following charges are not covered:

Dental services not listed.

Charges for a procedure for which an active appliance was installed before the patient was covered.

A charge incurred while the patients coverage is not in effect.

Services not performed by a licensed dentist.

Cosmetic dentistry or services otherwise not reasonably necessary, or customarily performed, for thedental care of the covered individual.

Charges in excess of the amount shown in the Ontario Dental Association Fee Guide for GeneralPractitioners.

Dental services paid through any other sources, such as a government agency or any other insurer.

Dental Benefits:

Orthodontic ServicesYou are covered for Orthodontic Services as shown below:

Dental Service Benefit

Orthodontic Services covers 75% of the cost up to alifetime maximum benefit of$4,000 per person

Prior to the commencement of orthodontic treatments, the dentist should submit an orthodontic treatment

plan to Great-West Life which:

provides a classification of the malocculsion or malposition,

recommends and describes necessary treatment by orthodontic procedures,

estimates the duration over which treatment will be completed,

estimates the total charge for such treatment, and

is accompanied by cephalometric x-rays, study models and such other supporting evidence as Great-West Life may reasonably require.

Great-West Life will then inform you of the amount eligible for reimbursement under the Plan.

Monthly Installments

The total eligible charges scheduled to be made in accordance with an orthodontic treatment plan shall beconsidered to be made in equal monthly installments (except that the amount of the initial fee shall be 25%of the total treatment costs) over a period of time equal to the estimated duration of the orthodontictreatment plan. The first installment shall be considered to occur on the date on which the orthodonticappliances are first inserted, and subsequent installments shall be considered to occur at the end of eachmonth thereafter.


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If benefits are being paid at termination of coverage for orthodontic services, they will be continued forcharges incurred during the rest of the month progress, provided payment for that month has not alreadybeen made.

List of Orthodontic Services

This plan covers the following services:

Consultations

Pretreatment Diagnostic Services

-Diagnostic Models, X-rays

-Cephalometric work-up

Preventive and Interceptive Orthodontics (including Appliances and Maintenance)

Habit Inhibiting

Space Regaining

Space Maintenance

Cross Bite Correction

Dental Arch Expansion

Corrective Orthodontics

Removable and Fixed Appliance Therapy

Retention


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List of Dental Codes and ProceduresThis appendix contains a complete set of Ontario Dental Association (ODA) Fee Guide Codes covered under the VertexCustomer Management (Canada) Limited Dental Plan. You may refer to these codes to confirm proper billing by yourdentist. You may also wish to refer to the codes to better understand claim acceptance or rejection by Great-West Life.

Fee Guide Codes Procedure

CLASS A SERVICES 100% Payment

Examinations

01101,01102,01103 Initial examination of a newpatient

01202 Re-examination of aprevious patient(once every 9 months)

01203 Periodontal examination

(once every 9 months)

01204 Specific examination

01205 Emergency examination

Radiographic Examination and Interpretation (X-Ray)

02101,02102 Intraoral radiographscomplete, once every 3calendar years.

02111 to 02125 Introral radiographs (1 to15).

02131 to 02136 Intraoral, Occlusalradiographs

02141 to 02146 Intraoral, Bitewingradiographs, (from 1 to 6films), once every ninemonths.

02201 to 02204,02209 Extraoral Radiographs

02304 Sinus examination

02401,02402,02409 Sialography

02411,02412,02419 Use of radiopaque dyes todemonstrate lesions

02504,02509 Temporomandibular Jointradiographs

02601 Panoramic (full mouth)radiographs, limit onceevery three calendaryears.

02701 to 02704,02709 Cephalometric radiographs

02751,02752,02759 Tracing of radiographs

02801,02802,02809 Interpretation ofradiographs from anothersource - per unit of time

02921 Hand and wristradiographs

02931 to 02934,02939 Tomography radiographs

04101,04201,04311,04312,04321,04322,04401

Tests and laboratoryexaminations

04801 to 4803,04809,04911,04931

Diagnostic Photographs

05101 to 05104,05109 Treatment Planning

05201,05202,0520993111,93112,93119

Consultations (2 times percalendar year)

Preventive Services


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11101,11102,11107,11109,11111 to 11117,11119

Scaling and Polishing,once every nine months.This is referred to asprophylaxis (normalcleaning of teeth).

11201,11202,11203,11401,11402,11403,

Preventative recallpackages, once every ninemonths.

11301,11302,11303,11501,11502,11503

Preventative recallpackages, once every ninemonths for under age 18only.

12101,12102 Fluoride treatment onceevery nine months, up toand including, age 18.

13211 to 13214,13219,13231,13232,13239

Oral hygiene instruction

13301,13302 Finishing Restorations

13401,13409 Pit and Fissure sealant topermanent molars only,once every three calendaryears, up to and including,age 18.

13502 Protective Mouth Guard

13701,13702 Interproximal discing ofteeth

14101,14102,14201,14202

Control of Oral Habits

14311,14312,14319 Myofunctional Therapy

15101,15103,15104,15105,15201,15202,15301,15302,15401,15402,15403,15501,15601,15602,15603,15604

Space Maintainers

20111,20119,20121,20129,20131,20139

Carries, Trauma, and PainControl

Restorative Services

21111 to 21115 Primary teeth - amalgam

21211 to 21215 Permanent bicuspid andanterior teeth - amalgam

21221 to 21225 Permanent molars

21401 to 21405,23101 to 23105,23111 to 23115,23121 to 23123,23211 to 23215,23221 to 23225,23311 to 23315,23321 to 23325,23401 to 23405,

23411 to 23415,23501 to 23505,23511 to 23515

Retentive pinreinforcement, Acrylic orcomposite restorations

Surgical Services - Removal of Teeth,Removal of Erupted Tooth - Uncomplicated

71101 Single tooth

71109 Each additional tooth insame quadrant, sameappointment

71201,71209 Removal of erupted tooth(complicated)

72111,72119,72211,72219, 72221,72229,72231,72239

Removal of impacted tooth

72311,72319,72321,72329, 72331,72339

Removal of ResidualRoots

Anaesthesia

92101,92102,92212 to 92219,92222 to 92229,92302 to 92309,92411 to 92419,92421 to 92429,92431 to 92439,92441 to 92449

Anaesthesia

Periodontal ServicesForperiodontal disease and therapeutic treatmentonly, not preventative treatment

Non-surgical services

41101 to 41104,41109 Displacement Dressing

41221 to 41224,41229 Nervous and MuscularDisorders

41211 to 41214,41219 Oral Manifestations41231 to 41234,41239

41301,41302,41309 Desensitization

42111,42201,42311,42331,42339,42411,42421,42431,42441,42511,42521,42531,42551,42561,42581,42611,42621,42711

Surgical services


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Adjunctive services

43111,43211,43231,43241,43261,43271,43281,43289

Periodontal splinting

43311 to 43314,43319 Occlusion

43421 to 43426,43429 Root Planing

43511,43519 Antimicrobial agents

43611,43612 Periodontal appliances

43621 to 43623,43629,43631

Maintenance appliances

Endodontic Services

32221,32222,32231,3223232311 to 32314,

32321,32322

Pulpotomy, permanentteeth

33111,33115,33121,33125,33131,33135,33141,33145,33401,33402,33403

Root Canal Therapy

33601 to 33604 Apexification

33611 to 33614 Re-insertion of DentogenicMedia

34111,34112,34121,34122,34123,34131 to34134,34141,34142,34151 to 34153, 34161 to34164

Apicoectomy

34211,34212,34221 to 34224,34231 to 34234,34241,34242,34251 to 34254,34261 to 34264

Retrofilling

34411,3441234421 to 34423,34441 to 34446,34451 to 34453,

34511, 34521 to 34523

Miscellaneous SurgicalServices

39101,39201,39202,39211,39212,39311,39312,39313,39319

Miscellaneous EndodonticProcedures

42821 to 42823,42829 Post surgical treatment

42831,42832 Periodontalabscess/pericoronitis

Extensive Oral Surgery

72511,72519,72521,72529,72531,72539

Surgical exposure

72611,72619,72631,72639 Surgical movement

72711,72719 Surgical Enucleation

73111,73121 Alveoloplasy

73152 to 73154 Excision of bone

73161 Removal of bone

73211,73221 Gingivoplasty and/orstomatoplasty

73411 Vestibuloplasty

74111 to 74118,74631 to 74638

Surgical excision anddrainage

75111,75112,75121,75122 Surgical incision

76201 to 76204,76301 to 76304,76911 to 76913,76941,76949,76951,76952,76959,76961 to 76963

Fractures

77801 to 77803 Frenectomy

79111,79311 to 79313,79321,79322,79331 to 79333,79341 to 79343,79402 to 79404,79601 to 79604

Miscellaneous surgicalprocedures

Adjunctive General Services

96201,96202 Therapeutic injections

99333 In-office laboratoryprocedures

CLASS B SERVICES 85% Payment

Prosthodontic Services - Removable

51101 to 53712 ONCE EVERY 3CALENDAR YEARS

51101 Complete maxillarydenture

51102 Complete mandibulardenture

51103 Complete maxillary andmandibular dentures

51301 to 51303, Immediate and transitional51601 to 51603 dentures


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52101 to 52103 Transitional partial denture

52111 to 52113,52201 to 52203,52211 to 52213,52301 to 52303,52311 to 52313,52401 to 52403,

52411 to 52413,52501 to 52503,52511,52512,53101 to 53104,53111 to 53113,53201 to 53203,53205,53211 to 53213,53215

Dentures, partial, acrylic

53301,53302,53304,53401 to 53403,53501 to 53503,53611 to 53613,53621 to 53623,53701 to 53704,53711 to 53713

Complete and partialdenture

54201,54202,54209,54301 to 54303,54401 to 54403,54501 to 54503

Denture adjustments

55101,55102,55201 to 5520355301,55302,55401 to 55403,55501,55509

Denture repairs/additions

56211 to 56213,56221 to 56223,56231 to 56233,56241 to 56243,56251 to 56253,56261 to 56263,56311 to 56313,56321 to 56323,56331 to 56333,56341 to 56343,56411 to 56413

Denture rebasing andrelining

56511 to 56513,56521 to 56523

Tissue conditioning

Note:Denture Therapists/Denturists will be reimbursed

under the Denture Therapists Fee Guide for full upperand/or lower dentures at 85% once every 3 calendaryears. The fee for construction of full upper and/or lowerdentures by a Denture Therapist or Denturist includes labfees as set out in the Denturist Fee Guide. As such,separate lab fees are not reimbursed, as these areconsidered to be included in the allowable fees.

Major Restorative Services

22201,22211,22301,22311,22401,22411,22501,22511

Stainless steel crowns

24101 to 24104,24201 to 24203

Gold foil restorations

25111 to 25113,25511 Metal inlay restorations

25601 to 25605 Retentive pins25131 to 25133,25711 to 25713,25721 to 25723,25781 to 25784,25789,27111,27113,27114,27121,27201,27211,27301,27311,27501,27502,27601,27602,27711,27721

Porcelain restorations

Other RestorativeServices

21301,21302,23601,25741 to 25743,25751,25752,27401,27409,29101 to 29103,29109,29301 to 29303,29309

Other restorative services

Prosthodontic Services -Fixed

62101,62103,62501,62502,62701,62702

Pontics

66111,66112,66113,66119 Repairs, Replacement

66711,66719 Porcelain repair

67321,67322,67331,67341 Retainers, Metal

67101,67102,67121,67129,67131,67201,67211,67212,67301,67311,67312,67501,67502

Retainers - Crowns

66211 to 66213,66219,

66301 to 66303,66309

Removal/Repairs to Fixed

Bridge

69201 Splinting

69301 to 69305 Retentive pins in fixedprosthetics

69701,69702 Provisional coverage

TemporomandibularJoint Appliances


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43711,43712,43721,43722,43731 to 43733,43739,43741

Temporomandubular JointAppliances andmaintenance charges, to alifetime maximum of$1,300.00 per person.Reinstatement of the$1,300 maximum after aperiod of five years fromthe date of purchase, on

recommendation of aphysician.

PWU Benefits Booklet-Vertex

Documents

Transcript of PWU Benefits Booklet-Vertex