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Common use of Major Medical Benefits Clause in Contracts

Major Medical Benefits. The City shall provide eligible CSU 52 members, that are participating in the Supplementary Health Care Plan and the Dental Plan, with a Direct Xxxx Card. The Card shall be consistent with that provided to other City of Edmonton employees. Eligible Expense % Reimbursement Maximum Benefit DRUGS Charges for drugs, medicines, allergy serums, allergy serum extracts and insulin which are purchased on a written prescription of a physician or dentist and dispensed by a licensed pharmacist, except that proprietary or patent medicines or drugs which can be purchased without a prescription will not be covered. 80% No maximum Smoking cessation products requiring a prescription by law. 80% One treatment plan per lifetime, per covered person. Oral contraceptives 80% $250 per calendar year Drugs for the management of obesity or weight loss, sexual dysfunction, fertility and hair replacement are not eligible for reimbursement. Reimbursement under this article will be made on the following basis:  Least cost alternative  $5.00 dispensing fee cap  Recognized third party drug formulary. New drugs that become available will The plan will pay in such calendar year in accordance with the following schedule of benefits: 6.02.01 Eligible Expense % Reimbursement Maximum Benefit be reviewed to determine if they will be added to the formulary. 6.02.02 AMBULANCE Charges for professional ambulance services when required due to illness or injury. This includes air transportation where ground transportation is either not available or not medically recommended. Such charges are limited to those incurred within Canada. 80% No maximum 6.02.03 BRACES AND PROSTHETICS The usual and reasonable costs of artificial limbs (excepting myoelectric- controlled prosthesis), artificial eyes, braces which incorporate a rigid support of metal or plastic, trusses, cervical collars, and breast prosthesis as a result of a mastectomy, manufactured according to the specifications on the written order of a physician, and necessary repairs or replacement of such appliances if such repairs or replacement are performed on the written order of a physician. All such appliances must be required to treat an existing medical condition. Repair or replacement of a breast prosthesis shall not require the written order of a physician, however such replacement or repair shall be limited to once in 24 months. 80% $2,000 per calendar year 6.02.04 HOME NURSING Medical care provided, on the written order of a physician, in the member's home, to a member or a member's dependent, by a practical or registered nurse who is not related to the member or their dependents. Homemaking services are not included. This benefit shall be limited to situations where it is medically shown that the person in respect of whom the services are rendered is suffering from a chronic and/or debilitating condition. 80% $2,000 per calendar year Eligible Expense % Reimbursement Maximum Benefit

Appears in 3 contracts

Samples: Collective Agreement, Collective Agreement, Collective Agreement

Major Medical Benefits. The City shall provide eligible CSU 52 members, that are participating in the Supplementary Health Care Plan and the Dental Plan, with a Direct Xxxx Card. The Card shall be consistent with that provided to other City of Edmonton employees. Eligible Expense % Reimbursement Maximum Benefit DRUGS Charges for drugs, medicines, allergy serums, allergy serum extracts and insulin which are purchased on a written prescription of a physician or dentist and dispensed by a licensed pharmacist, except that proprietary or patent medicines or drugs which can be purchased without a prescription will not be covered. 80% No maximum Smoking cessation products requiring a prescription by law. 80% One treatment plan per lifetime, per covered person. Oral contraceptives 80% $250 per calendar year Drugs for the management of obesity or weight loss, sexual dysfunction, fertility and hair replacement are not eligible for reimbursement. Reimbursement under this article will be made on the following basis:  Least cost alternative  $5.00 dispensing fee cap  Recognized third party drug formulary. New drugs that become available will The plan will pay in such calendar year in accordance with the following schedule of benefits: 6.02.01 Eligible Expense % Reimbursement Maximum Benefit be reviewed to determine if they will be added to the formulary. 6.02.02 AMBULANCE Charges for professional ambulance services when required due to illness or injury. This includes air transportation where ground transportation is either not available or not medically recommended. Such charges are limited to those incurred within Canada. 80% No maximum 6.02.03 BRACES AND PROSTHETICS The usual and reasonable costs of artificial limbs (excepting myoelectric- controlled prosthesis), artificial eyes, braces which incorporate a rigid support of metal or plastic, trusses, cervical collars, and breast prosthesis as a result of a mastectomy, manufactured according to the specifications on the written order of a physician, and necessary repairs or replacement of such appliances if such repairs or replacement are performed on the written order of a physician. All such appliances must be required to treat an existing medical condition. Repair or replacement of a breast prosthesis shall not require the written order of a physician, however such replacement or repair shall be limited to once in 24 months. 80% $2,000 per calendar year 6.02.04 HOME NURSING Medical care provided, on the written order of a physician, in the member's home, to a member or a member's dependent, by a practical or registered nurse who is not related to the member or their dependents. Homemaking services are not included. This benefit shall be limited to situations where it is medically shown that the person in respect of whom the services are rendered is suffering from a chronic and/or debilitating condition. 80% $2,000 per calendar year Eligible Expense % Reimbursement Maximum Benefit

Appears in 2 contracts

Samples: Collective Agreement, Collective Agreement

Major Medical Benefits. The City shall provide eligible CSU 52 members, that are participating in the Supplementary Health Care Plan and the Dental Plan, with a Direct Xxxx Card. The Card shall be consistent with that provided to other City of Edmonton employees. The plan will pay in such calendar year in accordance with the following schedule of benefits: Eligible Expense % Reimbursement Maximum Benefit Benefit 6.02.01 DRUGS Charges for drugs, medicines, allergy serums, allergy serum extracts and insulin which are purchased on a written prescription of a physician or dentist and dispensed by a licensed pharmacist, except that proprietary or patent medicines or drugs which can be purchased without a prescription will not be covered. 80% No maximum Smoking cessation products requiring a prescription by law. 80% One treatment plan per lifetime, per covered person. Oral contraceptives 80% $250 per calendar year Drugs for the management of obesity or weight loss, sexual dysfunction, fertility and hair replacement are not eligible for reimbursement. Reimbursement under this article will be made on the following basis:  Least cost alternative Cost Alternative  $5.00 dispensing fee cap  Recognized third party drug formulary. New drugs that become available will The plan will pay in such calendar year in accordance with the following schedule of benefits: 6.02.01 Eligible Expense % Reimbursement Maximum Benefit be reviewed to determine if they will be added to the formulary. 6.02.02 AMBULANCE Charges for professional ambulance services when required due to illness or injury. This includes air transportation where ground transportation is either not available or not medically recommended. Such charges are limited to those incurred within Canada. 80% No maximummaximum Eligible Expense % Reimbursement Maximum Benefit 6.02.03 BRACES AND PROSTHETICS The usual and reasonable costs of artificial limbs (excepting myoelectric- controlled prosthesis), artificial eyes, braces which incorporate a rigid support of metal or plastic, trusses, cervical collars, and breast prosthesis as a result of a mastectomy, manufactured according to the specifications on the written order of a physician, and necessary repairs or replacement of such appliances if such repairs or replacement are performed on the written order of a physician. All such appliances must be required to treat an existing medical condition. Repair or replacement of a breast prosthesis shall not require the written order of a physician, however such replacement or repair shall be limited to once in 24 months. 80% $2,000 per calendar year 6.02.04 HOME NURSING Medical care provided, on the written order of a physician, in the member's home, to a member or a member's dependent, by a practical or registered nurse who is not related to the member or their dependents. Homemaking services are not included. This benefit shall be limited to situations where it is medically shown that the person in respect of whom the services are rendered is suffering from a chronic and/or debilitating condition. 80% $2,000 per calendar year 6.02.05 PSYCHOLOGIST The services of a clinical psychologist engaged in the treatment of a mental or emotional illness of a member or their dependents. 80% $1,000 per calendar year Eligible Expense % Reimbursement Maximum Benefit 6.02.06 RESPIRATORY The usual and reasonable costs for the purchase or rental of respiratory equipment including oxygen, on the written order of a physician. Air cleaning devices, ionizing machines, vaporizers and humidifiers are excluded. 80% $2,500 per calendar year 6.02.07 COLOSTOMY, ILEOSTOMY AND UROSTOMY SUPPLIES The usual and customary charges for colostomy, ileostomy, urostomy, and adult incontinence supplies upon written order of a physician. DIABETIC SUPPLIES The usual and reasonable charges for supplies required for the administration of insulin (syringes and needles) and testing materials used by diabetics, upon written order of a physician. The usual and reasonable charges for insulin pumps. 80% No maximum 6.02.08 PHYSIOTHERAPY For services rendered by a qualified physiotherapist. 80% $1,000 per calendar year 6.02.09 CHIROPRACTOR For services rendered by a licensed chiropractor. The Plan shall not pay for such services until the allowable limits under the Alberta Health Care Plan have been reached. A letter from Alberta Health Care stating the date the maximum was attained shall be submitted with the claim. 80% $1,000 per calendar year 6.02.10 PODIATRIST For services rendered by a licensed podiatrist. The Plan shall not pay for such services until the allowable limits under the Alberta Health Care Plan have been reached. A letter from Alberta Health Care stating the date the maximum was attained shall be submitted with the claim. 80% $500 per calendar year Eligible Expense % Reimbursement Maximum Benefit 6.02.11 ACUPUNCTURE For acupuncture services, provided it is administered as a pain reliever or anaesthetic. 80% $500 per calendar year 6.02.12 HEARING AIDS For the purchase and repair of hearing aids as prescribed by a physician. Maintenance, batteries and recharging devices are excluded. 80% $2,500 in any five consecutive calendar year period 6.02.13 EYE EXAMS For eye examinations administered by an optometrist or ophthalmologist. Reimbursement shall be based only on amounts not paid by the Alberta Health Care Plan. 80% $80 per covered person in any two consecutive calendar year period 6.02.14 MASSAGE THERAPY For services rendered by a registered massage therapist. 80% $1,000 per calendar year 6.02.15 The supplies noted in this section will only be provided under this Plan if they are not provided by the Alberta Aids to Daily Living Plan or any similar plan which provides these benefits to members at no cost. 6.02.16 Claims must be received by the plan adjudicator no later than April 30 of the calendar year following the year in which the expense was incurred and shall include all receipts, prescription numbers for drugs, first and family names of individuals receiving drugs or services and dates when services were provided. Claims received on or after May 1 will not be honoured. The member shall be responsible for the accuracy of claims submitted. Claims submitted for expenses not incurred will be subject to disciplinary action up to and including dismissal.

Appears in 1 contract

Samples: Collective Agreement