Common use of Plan Details Clause in Contracts

Plan Details. (i) This plan shall cover the employee, the employee’s spouse and all other dependents under twenty- one (21) years of age, or a dependent who is between the ages of twenty-one (21) and twenty- five (25) and is a full-time student attending an educational institution or a mentally or physically handicapped child of an employee, provided such child is unmarried, twenty-one (21) years of age or over, dependent upon such employee for support and was mentally or physically handicapped and insured as a dependent immediately prior to age twenty-one (21); (ii) A pay-direct prescription drug card will be issued to all eligible employees to be utilized at pharmacies which honour this card system, upon completion of the enrollment process which includes the positive enrollment of all covered individuals (employees and dependents) and spousal coordination of benefits information. In instances where the pay-direct drug card cannot be utilized, the claim may be submitted to the insurance carrier on the prescribed paper form. The following is the drug plan coverage provided for eligible employees and dependents under either method of claim submission: (a) Ninety percent (90%) of reasonable and customary medically necessary expenses incurred for drugs and medicines requiring a prescription by law, vaccinations and serums (defined as preventative vaccines for Hepatitis A and/or B, Influenza, Meningitis and Chicken Pox with a drug identification number (DIN), and allergy serums as prescribed by a physician and administered by a qualified health care practitioner if they are not covered by a provincial health plan), and other specified life-sustaining drugs as defined and administered by the insurer and subject to change from time to time if they are: (i) Prescribed by a physician, nurse practitioner, where applicable, or dentist for the treatment of a diagnosed illness or injury, and (ii) Dispensed by a licensed pharmacist or by a physician or dentist legally licensed to dispense drugs, (b) Suchcoveredprescriptiondrugsandmedicines will be subject to generic substitution and an eight dollars ($8.00) maximum dispensing fee for each prescription. If the prescription specifically prescribes no generic substitution, then the brand name drug will be covered. (iii) Eligible expenses include: (a) Charges by a licensed hospital for semi- private room and board and for hospital services and supplies furnished for care and treatment, up to two hundred and forty dollars ($240.00) per day, effective August 1, 2017 (for expenses incurred after that date). (b) Charges for private duty nursing in your home by a registered graduate nurse, registered nursing assistant or licensed practical nurse (or designated equivalent) who is not ordinarily a resident in your home and is not related to you or to your dependents, provided the service was recommended and approved by a licensed physician or surgeon. (c) Artificial limbs and eyes, crutches, splints, casts, trusses and braces. (d) Rental of wheelchairs, hospital beds or iron lungs required for temporary therapeutic use. A wheelchair may be purchased if recommended by the attending physician and if rental cost would exceed the purchase cost. (e) Oxygen and its administration.

Plan Details. (i) This this plan shall cover the employee, the employee’s spouse and all other dependents under twenty- twenty-one (21) years of age, or a dependent who is between the ages of twenty-twenty- one (21) and twenty- twenty-five (25) and is a full-time student attending an educational institution or a mentally or physically handicapped child of an employee, provided such child is unmarried, twenty-one (21) years of age or over, dependent upon such employee for support and was mentally or physically handicapped and insured as a dependent immediately prior to age twenty-one (21); (ii) A pay-direct prescription drug card will be issued to all eligible employees to be utilized at pharmacies which honour this card system, upon completion of the enrollment process which includes the positive enrollment of all covered individuals (employees and dependents) and spousal coordination of benefits information. In instances where the pay-direct drug card cannot be utilized, the claim may be submitted to the insurance carrier on the prescribed paper form. The following is the drug plan coverage provided for eligible employees and dependents under either method of claim submission: (a) Ninety percent (90%) of reasonable and customary medically necessary expenses incurred for drugs and medicines requiring a prescription by law, vaccinations and serums (defined as preventative vaccines for Hepatitis A and/or B, Influenza, Meningitis and Chicken Pox with a drug identification number (DIN), and allergy serums as prescribed by a physician and administered by a qualified health care practitioner if they are not covered by a provincial health plan), and other specified life-sustaining drugs as defined and administered by the insurer and subject to change from time to time if they are: (i) Prescribed by a physician, nurse practitioner, where applicable, or dentist for the treatment of a diagnosed illness or injury, and (ii) Dispensed by a licensed pharmacist or by a physician or dentist legally licensed to dispense drugs, (b) Suchcoveredprescriptiondrugsandmedicines Such covered prescription drugs and medicines will be subject to generic substitution and an eight dollars ($8.00) maximum dispensing fee for each prescription. If the prescription specifically prescribes no generic substitution, then the brand name drug will be covered. (iii) Eligible expenses include: (a) Charges by a licensed hospital for semi- private room and board and for hospital services and supplies furnished for care and treatment, up to two one hundred and forty seventy dollars ($240.00170.00) per day, effective August September 1, 2017 2005 (for expenses incurred after that date). (b) Charges for private duty nursing in your home by a registered graduate nurse, registered nursing assistant or licensed practical nurse (or designated equivalent) who is not ordinarily a resident in your home and is not related to you or to your dependents, provided the service was recommended and approved by a licensed physician or surgeon. (c) Artificial limbs and eyes, crutches, splints, casts, trusses and braces. (d) Rental of wheelchairs, hospital beds or iron lungs required for temporary therapeutic use. A wheelchair may be purchased if recommended by the attending physician and if rental cost would exceed the purchase cost. (e) Oxygen and its administration.

Plan Details. (i) This this plan shall cover the employee, the employee’s spouse and all other dependents under twenty- twenty-one (21) years of age, or a dependent who is between the ages of twenty-twenty- one (21) and twenty- twenty-five (25) and is a full-time student attending an educational institution or a mentally or physically handicapped disabled child of an employee, provided such child is unmarried, twenty-one (21) years of age or over, dependent upon such employee for support and was mentally or physically handicapped disabled and insured as a dependent immediately prior to age twenty-one (21); (ii) A pay-direct prescription drug card will be issued to all eligible employees to be utilized at pharmacies which honour this card system, upon completion of the enrollment process which includes the positive enrollment of all covered individuals (employees and dependents) and spousal coordination of benefits information. In instances where the pay-direct drug card cannot be utilized, the claim may be submitted to the insurance carrier on the prescribed paper form. The following is the drug plan coverage provided for eligible employees and dependents under either method of claim submission: (a) Ninety percent (90%) of reasonable and customary medically necessary expenses incurred for drugs and medicines requiring a prescription by law, vaccinations and serums (defined as preventative vaccines for Hepatitis A and/or B, Influenza, Meningitis and Chicken Pox with a drug identification number (DIN), and allergy serums as prescribed by a physician and administered by a qualified health care practitioner if they are not covered by a provincial health plan), and other specified life-sustaining drugs as defined and administered by the insurer and subject to change from time to time if they are: (i) Prescribed by a physician, nurse practitioner, where applicable, or dentist for the treatment of a diagnosed illness or injury, and (ii) Dispensed by a licensed pharmacist or by a physician or dentist legally licensed to dispense drugs, (b) Suchcoveredprescriptiondrugsandmedicines Such covered prescription drugs and medicines will be subject to generic substitution and an eight dollars ($8.00) maximum dispensing fee for each prescription. If the prescription specifically prescribes no generic substitution, then the brand name drug will be covered. (iii) Eligible expenses include: (a) Charges by a licensed hospital for semi- semi-private room and board and for hospital services and supplies furnished for care and treatment, up to two hundred and forty dollars ($240.00) per day, effective August 1, 2017 (for expenses incurred after that date). (b) Charges for private duty nursing in your home by a registered graduate nurse, registered nursing assistant or licensed practical nurse (or designated equivalent) who is not ordinarily a resident in your home and is not related to you or to your dependents, provided the service was recommended and approved by a licensed physician or surgeon. (c) Artificial limbs and eyes, crutches, splints, casts, trusses and braces. (d) Rental of wheelchairs, hospital beds or iron lungs required for temporary therapeutic use. A wheelchair may be purchased if recommended by the attending physician and if rental cost would exceed the purchase cost. (e) Oxygen and its administration.

Plan Details. (i) This this plan shall cover the employee, the employee’s spouse and all other dependents under twenty- twenty-one (21) years of age, or a dependent who is between the ages of twenty-one (21) and twenty- twenty-five (25) and is a full-time student attending an educational institution or a mentally or physically handicapped child of an employee, provided such child is unmarried, twenty-one (21) years of age or over, dependent upon such employee for support and was mentally or physically handicapped and insured as a dependent immediately prior to age twenty-one (21); (ii) A pay-direct prescription drug card will be issued to all eligible employees to be utilized at pharmacies which honour this card system, upon completion of the enrollment process which includes the positive enrollment of all covered individuals (employees and dependents) and spousal coordination of benefits information. In instances where the pay-direct drug card cannot be utilized, the claim may be submitted to the insurance carrier on the prescribed paper form. The following is the drug plan coverage provided for eligible employees and dependents under either method of claim submission: (a) Ninety percent (90%) % of reasonable and customary medically necessary expenses incurred for drugs and medicines requiring a prescription by law, vaccinations and serums (defined as preventative vaccines for Hepatitis A and/or B, Influenza, Meningitis and Chicken Pox with a drug identification number (DIN), and allergy serums as prescribed by a physician and administered by a qualified health care practitioner if they are not covered by a provincial health plan), and other specified life-life- sustaining drugs as defined and administered by the insurer and subject to change from time to time if they are: (i) Prescribed by a physician, nurse practitioner, where applicable, or dentist for the treatment of a diagnosed illness or injury, and (ii) Dispensed by a licensed pharmacist or by a physician or dentist legally licensed to dispense drugs, (b) Suchcoveredprescriptiondrugsandmedicines Such covered prescription drugs and medicines will be subject to generic substitution and an eight dollars ($8.00) 8.00 maximum dispensing fee for each prescription. If the prescription specifically prescribes no generic substitution, then the brand name drug will be covered. (iii) Eligible expenses include: (a) Charges by a licensed hospital for semi- private room and board and for hospital services and supplies furnished for care and treatment, up to two one hundred and forty seventy dollars ($240.00170.00) per day, effective August September 1, 2017 2005 (for expenses incurred after that date). (b) Charges for private duty nursing in your home by a registered graduate nurse, registered nursing assistant or licensed practical nurse (or designated equivalent) who is not ordinarily a resident in your home and is not related to you or to your dependents, provided the service was recommended and approved by a licensed physician or surgeon. (c) Artificial limbs and eyes, crutches, splints, casts, trusses and braces. (d) Rental of wheelchairs, hospital beds or iron lungs required for temporary therapeutic use. A wheelchair may be purchased if recommended by the attending physician and if rental cost would exceed the purchase cost. (e) Oxygen and its administration. (f) Hearing aids and eye glasses if required as a result of accidental injury. (g) Ambulance services. (h) Dental services and supplies which are provided by a dental surgeon within a period of eighteen (18) months following accident for treatment of accidental injury to natural teeth including replacement of such teeth or for the setting of a jaw fractured or dislocated in an accident, excluding any benefits payable under any provincial medical plan. (i) Charges for the services of a chiropractor, osteopath, chiropodist, naturopath, podiatrist, physiotherapist, speech therapist, massage therapist and acupuncturist to a maximum of thirty-five dollars ($35.00) per visit for each visit not subsidized by O.H.I.P. In any event, the reimbursement for the combined services of the listed practitioners shall not exceed Two Thousand Dollars ($2,000.00) per year. (j) Charges for the services of a psychologist up to fifty dollars ($50.00) per half (1/2) hour for individual psychotherapy and/or testing and thirty-five dollars ($35.00) for all other visits. (k) Fees for services rendered outside of Ontario, by a physician, surgeon or a specialist legally licensed to practice medicine, in excess of the charges which are allowed under the Provincial Health Insurance Plan, but not to exceed the amount specified in the Ontario Medical Association Tariff. (l) Charges for surgery by a podiatrist, performed in a podiatrist’s office to a maximum of one hundred and sixty dollars ($160.00). It is not necessary for the employee or dependents to be confined to hospital to be eligible for benefits under this plan.

Plan Details. (i) This this plan shall cover the employee, the employee’s 's spouse and all other dependents under twenty- twenty-one (21) years of age, or a dependent who is between the ages of twenty-one (21) and twenty- twenty-five (25) and is a full-time student attending an educational institution or a mentally retarded or physically handicapped child of an employee, provided such child is unmarried, twenty-one (21) years of age or over, dependent upon such employee for support and was mentally retarded or physically handicapped and insured as a dependent immediately prior to age twenty-one (21); (ii) A pay-direct prescription drug card will be issued to all eligible employees to be utilized at pharmacies which honour this card system, upon completion of the re-enrollment process which includes the positive enrollment of all covered individuals (employees and dependents) and spousal coordination of benefits information. In instances where the pay-direct drug card cannot be utilized, the claim may be submitted to the insurance carrier on the prescribed paper form. The following is the drug plan coverage provided for eligible employees and dependents under either method of claim submission, once the pay-direct drug cards have been issued and activated: (a) Ninety percent (90%) % of reasonable and customary medically necessary expenses incurred for drugs and medicines requiring a prescription by law, vaccinations and serums (defined as preventative vaccines for Hepatitis A and/or B, Influenza, Meningitis and Chicken Pox with a drug identification number (DIN), and allergy serums as prescribed by a physician and administered by a qualified health care practitioner if they are not covered by a provincial health plan), law and other specified life-life- sustaining drugs as defined and administered by the insurer and subject to change from time to time if they are: (i) Prescribed by a physician, nurse practitioner, where applicable, or dentist for the treatment of a diagnosed illness or injury, and (ii) Dispensed by a licensed pharmacist or by a physician or dentist legally licensed to dispense drugs, (b) Suchcoveredprescriptiondrugsandmedicines Such covered prescription drugs and medicines will be subject to generic substitution and an eight dollars ($8.00) 8.00 maximum dispensing fee for each prescription. If the prescription specifically prescribes no generic substitution, then the brand name drug will be covered. (iii) Eligible expenses include: (a) Charges by a licensed hospital for semi- private room and board and for hospital services and supplies furnished for care and treatment, up to two one hundred and forty seventy dollars ($240.00170.00) per day, effective August September 1, 2017 2005 (for expenses incurred after that date). (b) Charges for private duty nursing in your home by a registered graduate nurse, registered nursing assistant or licensed practical nurse (or designated equivalent) who is not ordinarily a resident in your home and is not related to you or to your dependents, provided the service was recommended and approved by a licensed physician or surgeon. (c) Artificial limbs and eyes, crutches, splints, casts, trusses and braces. (d) Rental of wheelchairs, hospital beds or iron lungs required for temporary therapeutic use. A wheelchair may be purchased if recommended by the attending physician and if rental cost would exceed the purchase cost. (e) Oxygen and its administration. (f) Hearing aids and eye glasses if required as a result of accidental injury. (g) Ambulance services. (h) Dental services and supplies which are provided by a dental surgeon within a period of eighteen (18) months following accident for treatment of accidental injury to natural teeth including replacement of such teeth or for the setting of a jaw fractured or dislocated in an accident, excluding any benefits payable under any provincial medical plan. (i) Charges for the services of a chiropractor, osteopath, chiropodist, naturopath, podiatrist, physiotherapist, speech therapist and massage therapist to a maximum of thirty-five dollars ($35.00) per visit for each visit not subsidized by O.H.I.P. In any event, the reimbursement for the combined services of the listed practitioners shall not exceed Two Thousand Dollars ($2,000.00) per year. (j) Charges for the services of a psychologist up to fifty dollars ($50.00) per half (1/2) hour for individual psychotherapy and/or testing and thirty-five dollars ($35.00) for all other visits. (k) Fees for services rendered outside of Ontario, by a physician, surgeon or a specialist legally licensed to practice medicine, in excess of the charges which are allowed under the Provincial Health Insurance Plan, but not to exceed the amount specified in the Ontario Medical Association Tariff. (l) Charges for surgery by a podiatrist, performed in a podiatrist's office to a maximum of one hundred and sixty dollars ($160.00).

Plan Details. (i) This this plan shall cover the employee, the employee’s spouse and all other dependents under twenty- twenty-one (21) years of age, or a dependent who is between the ages of twenty-one (21) and twenty- twenty-five (25) and is a full-time student attending an educational institution or a mentally or physically handicapped child of an employee, provided such child is unmarried, twenty-one (21) years of age or over, dependent upon such employee for support and was mentally or physically handicapped and insured as a dependent immediately prior to age twenty-one (21); (ii) A pay-direct prescription drug card will be issued to all eligible employees to be utilized at pharmacies which honour this card system, upon completion of the enrollment process which includes the positive enrollment of all covered individuals (employees and dependents) and spousal coordination of benefits information. In instances where the pay-direct drug card cannot be utilized, the claim may be submitted to the insurance carrier on the prescribed paper form. The following is the drug plan coverage provided for eligible employees and dependents under either method of claim submission: (a) Ninety percent (90%) % of reasonable and customary medically necessary expenses incurred for drugs and medicines requiring a prescription by law, vaccinations and serums (defined as preventative vaccines for Hepatitis A and/or B, Influenza, Meningitis and Chicken Pox with a drug identification number (DIN), and allergy serums as prescribed by a physician and administered by a qualified health care practitioner if they are not covered by a provincial health plan), and other specified life-sustaining drugs as defined and administered by the insurer and subject to change from time to time if they are: (i) Prescribed by a physician, nurse practitioner, where applicable, or dentist for the treatment of a diagnosed illness or injury, and (ii) Dispensed by a licensed pharmacist or by a physician or dentist legally licensed to dispense drugs, (b) Suchcoveredprescriptiondrugsandmedicines Such covered prescription drugs and medicines will be subject to generic substitution and an eight dollars ($8.00) 8.00 maximum dispensing fee for each prescription. If the prescription specifically prescribes no generic substitution, then the brand name drug will be covered. (iii) Eligible expenses include: (a) Charges by a licensed hospital for semi- private room and board and for hospital services and supplies furnished for care and treatment, up to two one hundred and forty seventy dollars ($240.00170.00) per day, effective August September 1, 2017 2005 (for expenses incurred after that date). (b) Charges for private duty nursing in your home by a registered graduate nurse, registered nursing assistant or licensed practical nurse (or designated equivalent) who is not ordinarily a resident in your home and is not related to you or to your dependents, provided the service was recommended and approved by a licensed physician or surgeon. (c) Artificial limbs and eyes, crutches, splints, casts, trusses and braces. (d) Rental of wheelchairs, hospital beds or iron lungs required for temporary therapeutic use. A wheelchair may be purchased if recommended by the attending physician and if rental cost would exceed the purchase cost. (e) Oxygen and its administration.

Plan Details. (i) This this plan shall cover the employee, the employee’s 's spouse and all other dependents under twenty- twenty-one (21) years of age, or a dependent who is between the ages of twenty-one (21) and twenty- twenty-five (25) and is a full-time student attending an educational institution or a mentally retarded or physically handicapped child of an employee, provided such child is unmarried, twenty-one (21) years of age or over, dependent upon such employee for support and was mentally retarded or physically handicapped and insured as a dependent immediately prior to age twenty-one (21); (ii) A pay-direct prescription drug card will be issued to all eligible employees to be utilized at pharmacies which honour this card system, upon completion of the re-enrollment process which includes the positive enrollment of all covered individuals (employees and dependents) and spousal coordination of benefits information. In instances where the pay-direct drug card cannot be utilized, the claim may be submitted to the insurance carrier on the prescribed paper form. The following is the drug plan coverage provided for eligible employees and dependents under either method of claim submission, once the pay-direct drug cards have been issued and activated: (a) Ninety percent (90%) % of reasonable and customary medically necessary expenses incurred for drugs and medicines requiring a prescription by law, vaccinations and serums (defined as preventative vaccines for Hepatitis A and/or B, Influenza, Meningitis and Chicken Pox with a drug identification number (DIN), and allergy serums as prescribed by a physician and administered by a qualified health care practitioner if they are not covered by a provincial health plan), law and other specified life-life- sustaining drugs as defined and administered by the insurer and subject to change from time to time if they are: (i) Prescribed by a physician, nurse practitioner, where applicable, or dentist for the treatment of a diagnosed illness or injury, and (ii) Dispensed by a licensed pharmacist or by a physician or dentist legally licensed to dispense drugs, (b) Suchcoveredprescriptiondrugsandmedicines Such covered prescription drugs and medicines will be subject to generic substitution and an eight dollars ($8.00) 8.00 maximum dispensing fee for each prescription. If the prescription specifically prescribes no generic substitution, then the brand name drug will be covered. (iii) Eligible expenses include: (a) Charges by a licensed hospital for semi- private room and board and for hospital services and supplies furnished for care and treatment, up to two hundred and forty dollars ($240.00) per day, effective August 1, 2017 (for expenses incurred after that date). (b) Charges for private duty nursing in your home by a registered graduate nurse, registered nursing assistant or licensed practical nurse (or designated equivalent) who is not ordinarily a resident in your home and is not related to you or to your dependents, provided the service was recommended and approved by a licensed physician or surgeon. (c) Artificial limbs and eyes, crutches, splints, casts, trusses and braces. (d) Rental of wheelchairs, hospital beds or iron lungs required for temporary therapeutic use. A wheelchair may be purchased if recommended by the attending physician and if rental cost would exceed the purchase cost. (e) Oxygen and its administration.

Plan Details. (i) This this plan shall cover the employee, the employee’s spouse and all other dependents under twenty- twenty-one (21) years of age, or a dependent who is between the ages of twenty-twenty- one (21) and twenty- twenty-five (25) and is a full-time student attending an educational institution or a mentally or physically handicapped disabled child of an employee, provided such child is unmarried, twenty-one (21) years of age or over, dependent upon such employee for support and was mentally or physically handicapped disabled and insured as a dependent immediately prior to age twenty-one (21); (ii) A pay-direct prescription drug card will be issued to all eligible employees to be utilized at pharmacies which honour this card system, upon completion of the enrollment process which includes the positive enrollment of all covered individuals (employees and dependents) and spousal coordination of benefits information. In instances where the pay-direct drug card cannot be utilized, the claim may be submitted to the insurance carrier on the prescribed paper form. The following is the drug plan coverage provided for eligible employees and dependents under either method of claim submission: (a) Ninety percent (90%) of reasonable and customary medically necessary expenses incurred for drugs and medicines requiring a prescription by law, vaccinations and serums (defined as preventative vaccines for Hepatitis A and/or B, Influenza, Meningitis and Chicken Pox with a drug identification number (DIN), and allergy serums as prescribed by a physician and administered by a qualified health care practitioner if they are not covered by a provincial health plan), and other specified life-sustaining drugs as defined and administered by the insurer and subject to change from time to time if they are: (i) Prescribed by a physician, nurse practitioner, where applicable, or dentist for the treatment of a diagnosed illness or injury, and (ii) Dispensed by a licensed pharmacist or by a physician or dentist legally licensed to dispense drugs, (b) Suchcoveredprescriptiondrugsandmedicines Such covered prescription drugs and medicines will be subject to generic substitution and an eight dollars ($8.00) maximum dispensing fee for each prescription. If the prescription specifically prescribes no generic substitution, then the brand name drug will be covered. (c) The LCBO plan will not reimburse member costs for any prescription drug covered by the provincial plan for members or their dependents who are age 65 and over, other than the $100 personal deductible and $6.11 per script co-pay. (iii) Eligible expenses include: (a) Charges by a licensed hospital for semi- semi-private room and board and for hospital services and supplies furnished for care and treatment, up to two hundred and forty dollars ($240.00) per day, effective August 1, 2017 (for expenses incurred after that date). (b) Charges for private duty nursing in your home by a registered graduate nurse, registered nursing assistant or licensed practical nurse (or designated equivalent) who is not ordinarily a resident in your home and is not related to you or to your dependents, provided the service was recommended and approved by a licensed physician or surgeon. (c) Artificial limbs and eyes, crutches, splints, casts, trusses and braces. (d) Rental of wheelchairs, hospital beds or iron lungs required for temporary therapeutic use. A wheelchair may be purchased if recommended by the attending physician and if rental cost would exceed the purchase cost. (e) Oxygen and its administration. (f) Hearing aids and eye glasses if required as a result of accidental injury. (g) Ambulance services. (h) Dental services and supplies which are provided by a dental surgeon within a period of eighteen (18) months following accident for treatment of accidental injury to natural teeth including replacement of such teeth or for the setting of a jaw fractured or dislocated in an accident, excluding any benefits payable under any provincial medical plan. (i) Charges for the services of a chiropractor, osteopath, chiropodist, naturopath, podiatrist, physiotherapist, speech therapist, massage therapist and acupuncturist to a maximum of fifty ($50.00) per visit for each visit not subsidized by OHIP. In any event, the reimbursement for the combined services of the listed practitioners shall not exceed Two Thousand Dollars ($2,000.00) per year. (j) Charges for the services of a psychologist or social worker or Master of Social Work up to fifty dollars ($50.00) per half (1/2) hour per family member and group sessions, psychotherapy and/or testing and thirty-five dollars ($35.00) for all other purposes. (k) Fees for services rendered outside of Ontario, by a physician, surgeon or a specialist legally licensed to practice medicine, in excess of the charges which are allowed under the Provincial Health Insurance Plan, but not to exceed the amount specified in the Ontario Medical Association Tariff. (l) Charges for surgery by a podiatrist, performed in a podiatrist’s office to a maximum of one hundred and sixty dollars ($160.00). It is not necessary for the employee or dependents to be confined to hospital to be eligible for benefits under this plan.

Plan Details. (i) This this plan shall cover the employee, the employee’s spouse and all other dependents under twenty- twenty-one (21) years of age, or a dependent who is between the ages of twenty-twenty- one (21) and twenty- twenty-five (25) and is a full-time student attending an educational institution or a mentally or physically handicapped disabled child of an employee, provided such child is unmarried, twenty-one (21) years of age or over, dependent upon such employee for support and was mentally or physically handicapped disabled and insured as a dependent immediately prior to age twenty-one (21); (ii) A pay-direct prescription drug card will be issued to all eligible employees to be utilized at pharmacies which honour this card system, upon completion of the enrollment process which includes the positive enrollment of all covered individuals (employees and dependents) and spousal coordination of benefits information. In instances where the pay-direct drug card cannot be utilized, the claim may be submitted to the insurance carrier on the prescribed paper form. The following is the drug plan coverage provided for eligible employees and dependents under either method of claim submission: (a) Ninety percent (90%) of reasonable and customary medically necessary expenses incurred for drugs and medicines requiring a prescription by law, vaccinations and serums (defined as preventative vaccines for Hepatitis A and/or B, Influenza, Meningitis and Chicken Pox with a drug identification number (DIN), and allergy serums as prescribed by a physician and administered by a qualified health care practitioner if they are not covered by a provincial health plan), and other specified life-sustaining drugs as defined and administered by the insurer and subject to change from time to time if they are: (i) Prescribed by a physician, nurse practitioner, where applicable, or dentist for the treatment of a diagnosed illness or injury, and (ii) Dispensed by a licensed pharmacist or by a physician or dentist legally licensed to dispense drugs, (b) Suchcoveredprescriptiondrugsandmedicines Such covered prescription drugs and medicines will be subject to generic substitution and an eight dollars ($8.00) maximum dispensing fee for each prescription. If the prescription specifically prescribes no generic substitution, then the brand name drug will be covered. (c) The LCBO plan will not reimburse member costs for any prescription drug covered by the provincial plan for members or their dependents who are age 65 and over, other than the $100 personal deductible and $6.11 per script co-pay. (iii) Eligible expenses include: (a) Charges by a licensed hospital for semi- semi-private room and board and for hospital services and supplies furnished for care and treatment, up to two hundred and forty dollars ($240.00) per day, effective August 1, 2017 (for expenses incurred after that date). (b) Charges for private duty nursing in your home by a registered graduate nurse, registered nursing assistant or licensed practical nurse (or designated equivalent) who is not ordinarily a resident in your home and is not related to you or to your dependents, provided the service was recommended and approved by a licensed physician or surgeon. (c) Artificial limbs and eyes, crutches, splints, casts, trusses and braces. (d) Rental of wheelchairs, hospital beds or iron lungs required for temporary therapeutic use. A wheelchair may be purchased if recommended by the attending physician and if rental cost would exceed the purchase cost. (e) Oxygen and its administration.