Common use of Covered Expenses Clause in Contracts

Covered Expenses. Ambulance transportation to the nearest centre where adequate treatment is available Private room and board in a hospital in Canada For out-of-province accommodation, any difference between the hospital's standard xxxx rate and the government authorized allowance in your home province is covered. Great-West Life also covers the hospital facility fee related to dental surgery and any out-of-province hospital out-patient charges not covered by the government health plan in your home province. Room and board in a licensed private hospital up to per day to a maximum of days per condition Convalescent care for a condition that will significantly improve as a result of the care, starts within hours of confinement for acute care which has lasted or more days. The government authorized for accommodation in a nursing home. Residences established primarily for senior citizens or which provide personal rather than medical care are not covered. Services of a registered nurse, licensed practical nurse or registered nursing assistant who is not a member of your family, but only if the patient requires the specific skills of a trained nurse You should apply for a assessment before home nursing begins Chronic care, provided in a hospital, nursing home or for home nursing care, for a condition where improvement or deterioration is unlikely within the next months Drugs and drug supplies described below when provided in Canada. Benefits for drug expenses outside Canada are payable only as provided under the care provision. Drugs which require the written prescription of a physician or dentist, including oral contraceptives Injectable drugs including vitamins and vitamins, and allergy extracts. Syringes for self-administered injections are also covered Disposable needles for use with insulin injection devices, lancets and test strips Extemporaneous preparations or compounds if one of the ingredients is a covered drug Certain other drugs that do not require a prescription by may be covered when prescribed by your physician or dentist. If you have any questions, contact your plan administrator before incurring the expense. The plan will also pay for vaccines used to prevent disease For drugs eligible under a provincial drug plan, coverage is limited to the deductible amount and coinsurance you are required to pay under that plan. Rental or, at Life's discretion, purchase of certain medical supplies, appliances and prosthetic devices prescribed by a doctor Custom-made foot orthotics and custom fitted orthopedic shoes, including modifications to orthopedic footwear Hearing aids including repairs, batteries, tubing and ear molds provided at the time of purchase Diabetic supplies: Novolin-pens or similar insulin injection devices using a needle, blood-lettingdevices including platforms but not lancets. Lancets are covered under prescription drugs Blood-glucose monitoring machines Diagnostic x-rays and lab tests Out-of-hospital treatment of muscle and bone disorders, including diagnostic x-rays, by a licensed chiropractor Out-of-hospital treatment of movement disorders by a licensed physiotherapist Visioncare Glasses and contact lenses required to correct vision when provided by a licensed ophthalmologist, optometrist or optician For information on available discounts on and vision care services, refer to the Preferred Vision Services section of this booklet following the Healthcare benefit. Care Emergency care outside Canada is covered if it is required as a result of a medical emergency arising while you or your dependent is temporarily outside Canada for vacation, business or education purposes. To qualify for benefits, you must be covered by the government health plan in your home province.

Covered Expenses. Ambulance transportation to the nearest centre where adequate treatment is available Private room and board in a hospital in Canada For out-of-province accommodation, any difference between the hospital's ’s standard xxxx rate and the government authorized allowance in your home province is covered. Great-West Life also covers the hospital facility fee related to dental surgery and any out-of-province hospital out-patient charges not covered by the government health plan in your home province. Room and board in a licensed private hospital up to per day to a maximum of days per condition Convalescent care for a condition that will significantly improve as a result of the care, starts within hours of care and follows a confinement for acute care which has lasted or more days. The plan covers the government authorized for accommodation in a nursing home. Residences established primarily for senior citizens or which provide personal rather than medical care are not covered. home Services of a registered nurse, licensed practical nurse or registered nursing assistant who is not a member of your family, but only if the patient requires the specific skills of a trained nurse You should apply for a assessment before home nursing begins Chronic care, provided in a hospital, nursing home or for home nursing care, for a condition where improvement or deterioration is unlikely within the next months Drugs and drug supplies described below when provided in Canada. Benefits for drug expenses outside Canada are payable only as provided under the care provision. Drugs medicines which require the written prescription of a physician or dentistdentist and are dispensed by a licensed pharmacist, including oral if you are not eligible to receive them under a provincial drug benefit plan, including: Oral contraceptives Injectable drugs including vitamins and vitamins, and allergy extracts. Syringes for self-administered injections are also covered Disposable needles for use with insulin injection devices, lancets and test strips Extemporaneous preparations or compounds if one of the ingredients is a covered drug Certain other drugs that do not require a prescription by law may be covered when if they are listed in the current Compendium of Pharmaceuticals and Specialties, prescribed by your physician or dentist. If you have any questions, contact your plan administrator before incurring the expense. The Unless your doctor has prescribed a drug by its brand name and has specified in writing that the product is not to be interchanged, the plan will also pay for vaccines used to prevent disease For drugs eligible under a provincial drug plan, coverage is limited to cover only the deductible amount and coinsurance you are required to pay under that plancost of the lowest priced equivalent generic drug. Rental or, at Life's ’s discretion, purchase of certain medical supplies, appliances and prosthetic devices prescribed by a doctor Custom-made foot orthotics and custom fitted orthopedic shoes, including modifications to orthopedic footwear Hearing aids including repairs, batteries, tubing and ear molds provided at the time of purchase Diabetic supplies: Novolin-pens or similar insulin injection devices using a needle, blood-lettingdevices letting devices including platforms but not lancets. Lancets are covered under prescription drugs Blood-glucose monitoring machines Diagnostic x-rays and lab tests Out-of-hospital treatment of muscle and bone disorders, including diagnostic x-rays, by a licensed chiropractor Out-of-hospital treatment of movement disorders by a licensed physiotherapist treatment of foot disorders, including diagnostic by a licensed podiatrist treatment by a registered psychologist or qualified social worker treatment of speech impairments by a qualified speech therapist services of a licensed osteopath, including diagnostic x-rays services of a qualified massage therapist Visioncare Glasses and contact lenses required to correct vision when provided by a licensed ophthalmologist, optometrist or optician For information on available discounts on Global Medical Assistance Program This program provides medical assistance through a worldwide communications network which operates hours a day. The network locates medical services and vision care obtains West Life’s approval of covered services, refer to the Preferred Vision Services section of this booklet following the Healthcare benefit. Care Emergency care outside Canada is covered if it is when required as a result of a medical emergency arising while you or your dependent are travelling for vacation, business or education. Coverage for travel within Canada is temporarily limited to arising more than kilometres from home. The following services are covered, subject to West Life’s prior approval: hospital payment when required for admission If suitable local care is not available, medical evacuation to the nearest suitable hospital while travelling in Canada. If travel is outside Canada, transportation be provided to a hospital in Canada or to the nearest hospital outside Canada equipped to provide treatment Transportation and lodging for one family member joining a patient hospitalized for more than days while travelling alone. Benefits will be paid for a round trip economy class ticket and for moderate quality lodgings up to If you or a dependent is hospitalized while travelling with a companion, extra costs for moderate quality lodgings when the return trip is delayed due to the medical condition of yourself or dependent up to Benefits for lodging are limited to moderate quality accommodation for the area of hospitalization. Telephone expenses as well as taxicab and car rental charges are included. Meal expenses are not covered. If you or a dependent and a travelling companion miss prearranged, prepaid return transportation because of hospital confinement, the cost of comparable return transportation home for the patient and travelling companion is covered. Coverage is provided only when the return fare is not refundable. A rental vehicle is not considered prearranged, prepaid return transportation In the event of death, preparation and transportation of the deceased home Return transportation home for unaccompanied minor children and an escort when necessary if you or a dependent is hospitalized or dies Costs of returning your or your dependent’s vehicle home or to the nearest rental agency because of being unable to drive due to sickness or injury up to Benefits will not be paid for vehicle return if transportation reimbursement benefits are paid for the cost of comparable return transportation home Emergency Care Medical expenses incurred outside your home province are covered when you or your dependent is outside Canada for vacation, business or education purposespurposes and the expenses arise as a result of a medical The plan covers the following services and supplies related to the initial medical treatment: treatment by a physician diagnostic and laboratory services hospital accommodation in a standard or semi-private xxxx or intensive care unit, if the confinement begins while you or your dependent is covered medical supplies provided during a covered hospital confinement paramedical services provided during a covered hospital confinement hospital services and supplies medical supplies provided if they would have been covered in Canada drugs services of a professional nurse ambulance services by a licensed ambulance company to the nearest centre where essential treatment is available If you are being treated outside Canada and your medical condition permits you to return to Canada, benefits will be limited to the amount payable under this plan for continued treatment outside Canada or the amount payable under this plan for comparable treatment in Canada, plus return transportation, whichever is less. To qualify Limitations No benefits are paid for: Expenses private insurers are not permitted to cover by law Services and supplies the person is entitled to without charge by law or for benefitswhich a charge is made only because the person has insurance coverage Services and supplies that do not represent reasonable treatment Services and supplies associated with: treatment performed only for cosmetic purposes recreation or sports rather than with other daily living activities the diagnosis or treatment of infertility other than drugs contraception, you must be other than oral contraceptives Services or supplies not listed as covered expenses Extra medical supplies that are spares or alternates Services or supplies received outside Canada except as listed under Emergency Care and Global Medical Assistance Services or supplies received in Canada unless the person is covered by the government health plan in their home province and West Life would have paid benefits for the same services or supplies if they had been received in the person’s home province This limitation does not apply to Global Medical Assistance Expenses arising from war, insurrection, or voluntary participation in a riot Residences established primarily for senior citizens or which provide personal rather medical care Chronic care In addition under the prescription drug coverage, no benefits are paid for: Atomizers, appliances, prosthetic devices, colostomy supplies, first aid supplies, diagnostic supplies or testing equipment Non-disposable insulin delivery devices or spring loaded devices used to hold blood letting devices Delivery or extension devices for inhaled medications Oral vitamins, minerals, dietary supplements, homeopathic preparations, infant formulas or injectable total parenteral nutrition solutions Diaphragms, condoms, jellies, foams, sponges, suppositories, contraceptive implants or appliances Any drug that does not have a drug identification number as defined by the Food and Drugs Act, Canada Proprietary or patent medicines registered under the Food and Drugs Act, Canada Any single purchase of s which would not reasonably be used within days. In the case of certain maintenance drugs, a 00-day supply will be covered Drugs dispensed by a physician, surgeon, dentist or clinic or by a non-accredited hospital pharmacy Drugs dispensed during treatment as an in-patient or an out-patient in a hospital Preventative immunization vaccines and toxoids Non-injectable allergy extracts Drugs that are considered cosmetic, such as topical or sunscreens Chiropractic or podiatric treatments for which a portion of the cost is payable under the Ontario Health Insurance Plan Benefits for these services are payable only after the maximum annual benefit has been paid How to Make a Claim Out-of-province claims (other than those for Global Medical Assistance expenses) should be submitted to Great-West Life as soon as possible upon incurring the expense. It is very important that you send your home claims to our Benefit Payment Office immediately as your Provincial Medical Plan has very strict time limitations. Obtain form from your employer. Complete this form, making sure it shows all required information. Attach all original receipts and forward it to your local Great-West Life Benefit Payment Office (be sure to retain a copy for your own records.) Great-West Life will then send you an Out-of-Country Statement of Claim and Government Assignment forms. Complete these forms and return them to us. We will pay all eligible claims including your Provincial Medical Plan portion. Great-West Life will then be reimbursed directly from your Provincial Medical Plan for their share of the expenses. Out-of-Country claims must be submitted within a certain time period which varies with each province.. Please contact our Out-of-Country Claims unit for the time restriction for submitting claims in your province. If you have any questions or if assistance is required to complete any of the forms, please contact our Out-of-Country Claims Unit at For all other claims, obtain form (Healthcare) or form (Visioncare) from your employer. Complete this form making sure it shows all required information. Attach your receipts to the claim form and return it to the Benefit Payment Office as soon as possible, but no later than months after you incur the expense. For drug claims, your employer will provide you with a prescription drug identification card. Present your card when purchasing drugs at any of the participating pharmacies. Sign the prescription voucher (the pharmacy has this voucher) and pay the pharmacist the amount, if any, shown as the "deductible" on your card. When purchasing drugs at a non-participating pharmacy, you will be required to pay the full price of the prescription. For reimbursement, ask your employer for a prescription drug claim form. Attach your drug receipts to the complete claim form and return it to your employer. When your coverage ends, return your direct pay drug identification card to your employer. RE A deductible may be applied before you are reimbursed. All expenses will be reimbursed at the level shown in the Benefit Summary. Benefits may be subject to plan maximums and frequency limits. Check the Benefit Summary for this information. The plan covers reasonable and customary charges to the extent they do not exceed the dental fee guide level shown in the Benefit Summary. Treatment Pian Before incurring any large expenses, ask your dentist to complete a treatment plan and submit it to Life. Life will calculate the benefits payable for the proposed treatment, so you will know approximately in advance the portion of the cost you will have to pay. Basic Coverage The following expenses will be covered: Diagnostic services including: one complete oral examination every months limited oral examinations twice every months, except that only one limited oral examination is covered in any period that a complete oral examination is also performed limited periodontal examinations twice every months complete series of every months to a maximum of films every months and a panoramic every months. Services provided in the same months as a complete series are not covered Preventive services including: polishing and topical application of fluoride each twice every months scaling, limited to a maximum combined with periodontal root planing of time units every months A time unit is considered to be a interval or any portion of a interval pit and fissure sealants on bicuspids and permanent molars every months space including appliances for the control of harmful habits finishing restorations interproximal recontouring of teeth Minor restorative services including: caries, trauma, and pain control amalgam and tooth-coloured fillings. Replacement fillings are covered only if the existing filling is at least years old or the existing filling was not covered under this plan retentive pins and prefabricated posts for fillings prefabricated crowns for primary teeth Endodontics. Root canal therapy for permanent teeth will be limited to one course of treatment per tooth. Repeat treatment is covered only if the original treatment fails after the first months Periodontal services including: root planing, limited to a maximum combined with preventive scaling of time units every months occlusal adjustment equilibration, limited to a combined maximum of time units every months A time unit is considered to a 15-minute interval or any portion of a 15-minute interval Denture maintenance, after the 3-month post-insertion care period, including: denture relines for dentures at least months old, once every months denture for dentures at least years old, once every months resilient liner in relined or dentures, once every months Oral surgery Adjunctive services

Covered Expenses. Ambulance transportation Transportation by ambulance to the nearest centre where adequate treatment is available Private available, from one hospital to another hospital, and from a hospital to your residence Charges are also covered for the fare of one attendant to accompany you if transportation is not provided by a licensed ambulance service Semi-private room and board in a hospital in Canada For out-of-province accommodation, any difference between the hospital's standard xxxx rate and the government authorized allowance in your home province is covered. Great-West Life The plan also covers the hospital facility fee related to dental surgery and any out-of-province hospital out-patient charges not covered by the government health plan in your home province. Room and board in Supplies prescribed by a physician or surgeon which are obtained from an department of a licensed private hospital up or a surgical supply company, while you are not confined to per day to a maximum of days per condition the hospital. Convalescent care for a condition that will significantly improve as a result of the care, starts within hours of follows a 5-day confinement for acute care which has lasted and begins within hours after your release from the acute care confinement. Payment will not be made for more than days in any continuous period of confinement. "Continuous periods of confinement" includes all periods not separated by more than consecutive days for you, or by more daysthan consecutive days for your covered dependents. The government authorized for accommodation in a nursing home. Residences established primarily for senior citizens or which provide personal rather than medical care are not covered. Services Home nursing services of a registered nurse, licensed practical nurse or registered nursing assistant who is not a member of your family, but only if the patient requires the specific skills of a trained nurse You should apply for a assessment before home nursing begins Chronic care, provided in a hospital, nursing home or for home nursing care, for a condition where improvement or deterioration is unlikely within the next months O Drugs and drug supplies described below medicines which require the written prescription of a physician or dentist and are dispensed by a licensed pharmacist, as well as certain life-sustaining drugs, injectable drugs and syringes for self-administered injections, when provided in Canada. Benefits for drug expenses outside Canada are payable only as provided under the care provisionnot covered. Drugs which require the written prescription of a physician or dentist, including oral contraceptives Injectable drugs including vitamins and vitamins, and allergy extracts. Syringes for self-administered injections are also covered Disposable needles for use with insulin injection devices, lancets and test strips Extemporaneous preparations or compounds if one of the ingredients is a covered drug Certain other drugs that do not require a prescription by may be covered when prescribed by your physician or dentist. If you have any questions, contact your plan administrator before incurring the expense. The plan will also pay for vaccines used to prevent disease For drugs eligible under a provincial drug plan, coverage is limited to the deductible amount and coinsurance you are required to pay under that plan. O Rental or, at Life's discretion, purchase of certain medical supplies, appliances and prosthetic devices prescribed by a doctor O Custom-made foot orthotics and custom fitted orthopedic shoesshoes when: prescribed by a physician, including modifications to orthopedic footwear podiatrist or chiropodist, made from a plaster cast, diagnosed as being necessary by a biomechanical examination, made at a professional podiatry laboratory and medically necessary for your regular daily living activities and not solely for recreation or sports. O Hearing aids including repairsrepairs O Diabetic supplies including insulin, batteriessyringes, tubing pens, testing supplies and ear molds provided at the time of purchase Diabetic supplies: Novolin-pens or similar insulin injection devices using a needle, blood-lettingdevices including platforms but not lancets. Lancets are covered under prescription drugs Blood-glucose infusion sets O monitoring machines Diagnostic x-rays and lab tests Out-of-hospital the following breathing equipment and supplies: oxygen and the equipment needed for its administration, continuous positive airway pressure machines, supplies, and cushion masks, ultra mirage masks and nasal pillows. treatment of muscle and bone disorders, including diagnostic x-rays, by a licensed chiropractor Out-of-hospital treatment of movement disorders by a licensed physiotherapist services of a qualified massage therapist Visioncare Eye examinations, including refractions, when they are performed by a licensed ophthalmologist or optometrist Glasses and contact lenses required to correct vision when provided by a licensed ophthalmologist, optometrist or optician Contact lenses which are prescribed because the regular surface of the lens of the eye (the cornea) is impaired in some way and visual acuity cannot be improved to at least the level in the better eye with ordinary eyeglasses Visual training and remedial therapy required to correct faulty visual skills when performed by a licensed ophthalmologist or optometrist O Diagnosis and treatment of accidental injury or disease to the eyes Expenses listed above under Visioncare are covered only if they are recommended or approved by a legally licensed physician, surgeon, ophthalmologist or optometrist. For information on available discounts on eyewear and vision care services, refer to the Preferred Vision Services section of this booklet following booklet. Preferred Vision Services Preferred Vision Services is a service provided by West Life to its customers through Preferred Vision Services. Preferred Vision Services entitles you to a discount on a wide selection of quality eyewear and lens extras (scratch guarding, tints, etc.) when you purchase these items from a network optician or optometrist. You are eligible to receive the Healthcare benefitdiscount through the network whether or not you are enrolled for the healthcare coverage described in this booklet. Care Emergency You can use the network as often as you wish to purchase eyewear for yourself and your dependents at a reduced cost. Shopping for eyewear through Call the Information at or visit the Web site at for information about locations and the program O Arrange for a fitting or eye examination, if needed O Present your group benefit plan identification card to identify your preferred status as a member through Life at the time of purchase Select your eyewear and pay the reduced price. If you have vision care coverage, obtain a receipt and submit it with a claim form to Life in the usual manner. Limitations Except to the extent otherwise required by law, no benefits are paid for: Expenses private plans are not permitted to cover by law Services or supplies you are entitled to without charge by law or for which a charge is made only because you have coverage under a plan The portion of the expense for services or supplies that is payable by the government health plan in your home province, whether or not you are actually covered under the government health plan Services or supplies that do not represent reasonable treatment Services or supplies associated with: treatment performed only for cosmetic purposes recreation or sports rather than with other daily living activities the diagnosis or treatment of infertility contraception, other than oral contraceptives Services or supplies not listed as covered expenses Extra medical supplies that are spares or alternates Services or supplies received outside Canada is covered if it is required as a result of a medical emergency arising while Services or supplies received in Canada unless you or your dependent is temporarily outside Canada for vacation, business or education purposes. To qualify for benefits, you must be are covered by the government health plan in your home provinceprovince and benefits would have been paid under this plan for the same services or supplies if they had been received in your home province Expenses arising from war, insurrection, or voluntary participation in a riot Chronic care Chiropractic treatments for which a portion of the cost is payable under the Ontario Health Plan Benefits for these services are payable only after the maximum annual benefit has been paid Visioncare services and supplies required by an employer as a condition of employment Any drug or item which does not have a drug identification number as defined by the Food and Drugs Act, Canada Proprietary or patent medicines registered under the Food and Drugs Act, Canada Homeopathic preparations, unless federal or provincial legislation requires a prescription for their sale Vaccines used to prevent disease Fertility drugs, whether or not prescribedfor a medical reason Drugs used to treat erectile dysfunction How to Make a Claim Obtain form from your employer. Complete this form making sure it shows all required information. Attach your receipts to the claim form and return it to the Great-West Life Benefit Payment Office as soon as possible, but no later than months after you incur the expense.

Covered Expenses. Ambulance transportation to the nearest centre where adequate treatment is available Private room and board in a hospital in Canada For out-of-province accommodation, any difference between the hospital's standard xxxx rate and the government authorized allowance in your home province is covered. Great-West Life also covers the hospital facility fee related to dental surgery and any out-of-province hospital out-patient charges not covered by the government health plan in your home province. Room and board in a licensed private hospital up to per day to a maximum of days per condition Convalescent care for a condition that will significantly improve as a result of the care, starts within hours of care and follows a confinement for acute care which has lasted or more days. The government authorized for accommodation in a nursing home. Residences established primarily for senior citizens or which provide personal rather than medical care are not covered. Services of a registered nurse, licensed practical nurse or registered nursing assistant who is not a member of your family, but only if the patient requires the specific skills of a trained nurse You should apply for a assessment before home nursing begins Chronic care, provided in a hospital, nursing home or for home nursing care, for a condition where improvement or deterioration is unlikely within the next months Drugs and drug supplies described below when provided in Canada. Benefits for drug expenses outside Canada are payable only as provided under the emergency care provision. Drugs which require the written prescription of a physician or dentist, including oral contraceptives Injectable drugs including vitamins and vitamins, and allergy extracts. Syringes for self-administered injections are also covered Disposable needles for use with insulin injection devices, lancets and test strips Extemporaneous preparations or compounds if one of the ingredients is a covered drug Certain other drugs that do not require a prescription by law may be covered when prescribed by your physician or dentist. If you have any questions, contact your plan administrator before incurring the expense. The Unless your doctor has prescribed a drug by its brand name and has specified in writing that the product is not to be interchanged, the plan will also pay for vaccines used to prevent disease cover only the cost of the lowest priced equivalent generic drug. For drugs eligible under a provincial drug plan, coverage is limited to the deductible amount and coinsurance you are required to pay under that plan. Rental or, at Life's discretion, purchase of certain medical supplies, appliances and prosthetic devices prescribed by a doctor Custom-made foot orthotics and custom fitted orthopedic shoes, including modifications to orthopedic footwear Hearing aids including repairs, batteries, tubing and ear molds provided at the time of purchase Diabetic supplies: Novolin-pens or similar insulin injection devices using a needle, blood-lettingdevices letting devices including platforms but not lancets. Lancets are covered under prescription drugs Blood-glucose monitoring machines Diagnostic x-rays and lab tests Out-of-hospital treatment of muscle and bone disorders, including diagnostic x-rays, by a licensed chiropractor Out-of-hospital treatment of movement disorders by a licensed physiotherapist treatment of foot disorders, including diagnostic x- rays, by a licensed podiatrist treatment by a registered psychologist or qualified social worker treatment of speech impairments by a qualified speech therapist services of a qualified massage therapist services of a qualified acupuncturist x-rays Visioncare services of a licensed osteopath, including diagnostic services of a qualified naturopath Eye examinations, including refractions, when they are performed by a licensed ophthalmologist or optometrist Glasses and contact lenses required to correct vision when provided by a licensed ophthalmologist, optometrist or optician For information on available discounts on Medical Travel In Canada The plan will pay for the following expenses if you are referred away from home by your physician for treatment by another physician within your own province or elsewhere in Canada and vision care the round trip distance is kilometres or more. Travelling expenses for the person requiring the treatment and one companion if recommended by the attending physician. Benefits are limited to either round trip economy class travel or automobile fuel expenses. Taxicab, car rental charges and automobile repair charges are not covered. Lodging expenses for the person requiring the treatment and one companion. Benefits are limited to moderate quality accommodation for the area in which the expense is incurred. Telephone and meal expenses are not covered. Transportation and lodging expenses associated with medical travel are limited to a lifetime maximum of Global Medical Assistance Program This program provides medical assistance through a worldwide communications network which operates hours a day. The network locates medical services and obtains Life's approval of covered services, refer to the Preferred Vision Services section of this booklet following the Healthcare benefit. Care Emergency care outside Canada is covered if it is when required as a result of a medical emergency arising while you or your dependent is temporarily outside Canada travelling for vacation, business or education purposeseducation. To qualify Coverage for benefits, you travel within Canada is limited to emergencies arising more than kilometres from home. You must be covered by the government health plan in your home provinceprovince to be eligible for global medical assistance benefits. The following services are covered, subject to Life's prior approval: hospital payment when required for admission, to a maximum of If suitable local care is not available, medical evacuation to the nearest suitable hospital while travelling in Canada. If travel is outside Canada, transportation will be provided to a hospital in Canada or to the nearest hospital outside Canada equipped to provide treatment Transportation and lodging for one family member joining a patient hospitalized for more than days while travelling alone. Benefits will be paid for moderate quality lodgings up to and for a round trip economy class ticket If you or a dependent is hospitalized while travelling with a companion, extra costs for moderate quality lodgings for the companion when the return trip is delayed due to your or your dependent's medical condition, to a maximum of The cost of comparable return transportation home for you or a dependent and one travelling companion if prearranged, prepaid return transportation is missed because you or your dependent is hospitalized. Coverage is provided only when the return fare is not refundable. A rental vehicle is not considered prearranged, prepaid return transportation In case of death, preparation and transportation of the deceased home Return transportation home for minor children travelling with you or a dependent who are left unaccompanied because of your or your dependent's hospitalization or death. Return or round trip transportation for an escort for the children is also covered when considered necessary Costs of returning your or your dependent's vehicle home or to the nearest rental agency when illness or injury prevents you or your dependent from driving, to a maximum of Benefits will not be paid for vehicle return if transportation reimbursement benefits are paid for the cost of comparable return transportation home Benefits payable for moderate quality accommodation include telephone expenses as well as taxicab and car rental charges. Meal expenses are not covered.

Covered Expenses. Ambulance transportation to the nearest centre where adequate treatment is available Private room and board in a hospital in Canada For out-of-province accommodation, any difference between the hospital's standard xxxx rate and the government authorized allowance in your home province is covered. Great-West Life also covers the hospital facility fee related to dental surgery and any out-of-province hospital out-patient charges not covered by the government health plan in your home province. Room and board in a licensed private hospital up to per day to a maximum of days per condition Convalescent care for a condition that will significantly improve as a result of the care, starts within hours of confinement for acute care which has lasted or more days. The government authorized for accommodation in a nursing home. Residences established primarily for senior citizens or which provide personal rather than medical care are not covered. Services of a registered nurse, licensed practical nurse or registered nursing assistant who is not a member of your family, but only if the patient requires the specific skills of a trained nurse You should apply for a assessment before home nursing begins Chronic care, provided in a hospital, nursing home or for home nursing care, for a condition where improvement or deterioration is unlikely within the next months Drugs and drug supplies described below medicines which require the written prescription of a physician or dentist and are dispensed by a licensed pharmacist, as well as certain drugs, injectable drugs and syringes for self-administered injections, when provided in Canada. Benefits for drug expenses outside Canada are payable only as provided under the emergency care provision. Drugs which require the written prescription of a physician or dentist, including oral contraceptives Injectable drugs including vitamins and vitamins, and allergy extracts. Syringes for self-administered injections are also covered Disposable needles for use with insulin injection devices, lancets and test strips Extemporaneous preparations or compounds if one of the ingredients is a covered drug Certain other drugs that do not require a prescription by may be covered when prescribed by your physician or dentist. If you have any questions, contact your plan administrator before incurring the expense. The plan will also pay for vaccines used to prevent disease For drugs eligible under a provincial drug plan, coverage is limited to the deductible amount and coinsurance you are required to pay under that plan. Rental or, at Life's ’s discretion, purchase of certain medical supplies, appliances and prosthetic devices prescribed by a doctor Custom-made foot orthotics and custom fitted orthopedic shoes, including modifications to orthopedic footwear Hearing aids Diabetic supplies including repairsinsulin, batteriessyringes, tubing pens, testing supplies and ear molds provided at the time of purchase Diabetic supplies: Novolin-pens or similar insulin injection devices using a needle, blood-lettingdevices including platforms but not lancets. Lancets are covered under prescription drugs Blood-glucose infusion sets monitoring machines Diagnostic x-rays and lab tests Out-of-hospital treatment of muscle and bone disorders, including diagnostic x-rays, by a licensed chiropractor Out-of-hospital treatment of movement disorders by a licensed physiotherapist Visioncare Glasses and contact lenses required to correct vision Emergency Care Medical expenses incurred outside your home province are covered when provided by a licensed ophthalmologist, optometrist or optician For information on available discounts on and vision care services, refer to the Preferred Vision Services section of this booklet following the Healthcare benefit. Care Emergency care outside Canada is covered if it is required as a result of a medical emergency arising while you or your dependent is temporarily outside Canada for vacation, business or education purposespurposes and the expenses arise as a result of a medical emergency. To qualify The plan covers the following services and supplies related to the initial medical treatment: treatment by a physician diagnostic x-ray and laboratory services medical supplies provided if they would have been covered in Canada drugs services of a professional nurse ambulance services by a licensed ambulance company to the nearest centre where essential treatment is available If you are being treated outside Canada and your medical condition permits you to return to Canada, benefits will be limited to the amount payable under this plan for benefitscontinued treatment outside Canada or the amount payable under this plan for comparable treatment in Canada, you must be plus return transportation, whichever is less. emergency care does not include hospital room and board charges. You may obtain such coverage from a number of providers on an individual basis. Limitations No benefits are paid for: Expenses private insurers are not permitted to cover by law Services and supplies the person is entitled to without charge by law or for which a charge is made only because the person has insurance coverage Services and supplies that do not represent reasonable treatment Services and supplies associated with: treatment performed only for cosmetic purposes recreation or sports rather than with other daily living activities the diagnosis or treatment of infertility contraception, other than oral contraceptives Services or supplies not listed as covered expenses Extra medical supplies that are spares or alternates Services or supplies received outside Canada except as listed under Out-of-Country Emergency Care Services or supplies received out-of-province in Canada unless the person is covered by the government health plan in their home province and Great-West Life would have paid benefits for the same services or supplies if they had been received in the person’s home province Expenses arising from war, insurrection, or voluntary participation in a riot Residences established primarily for senior citizens or which provide personal rather than medical care Chronic care Any drug or item which does not have a drug identification number as defined by the Food and Drugs Act, Canada Proprietary or patent medicines registered under the Food and Drugs Act, Canada Homeopathic preparations, unless federal or provincial legislation requires a prescription for their sale Smoking cessation products Healthcare terminates when you reach age How to Make a Claim claims should be submitted to your home plan Administrator as soon as possible upon incurring the expense. It is very important that you send your claims immediately as your Provincial Medical Plan has very strict time limitations. Obtain form from your plan Administrator. Complete this form, making sure it shows all required information. Attach all original receipts and forward it to your plan Administrator (be sure to retain a copy for your own records). claims must be submitted within a certain time period which varies with each province. Please contact our Claims unit for the time restriction for submitting claims in your province. If you have any questions or if assistance is required to complete any of the forms, please contact our Claims Unit at For all other Healthcare claims, obtain form from your employer or the Administrator. Complete this form making sure it shows all required information. Attach your receipts to the claim form and return it to your plan Administrator as soon as possible, but no later than months after you incur the expense.

Covered Expenses. Ambulance transportation to the nearest centre where adequate treatment is available The difference between Semi-private and Private room and board in a hospital in Canada For out-of-province accommodation, any difference between the hospital's standard xxxx rate and the government authorized allowance in your home province is covered. Great-West Life also covers the hospital facility fee related to dental surgery and any out-of-province hospital out-patient charges not covered by the government health plan in your home province. Room and board in a licensed private hospital up to per day to a maximum of days per condition Convalescent care for a condition that will significantly improve as a result of the care, starts within hours of confinement for acute care which has lasted or more days. The government authorized for accommodation in a nursing home. Residences established primarily for senior citizens or which provide personal rather than medical care are not covered. Services of a registered nurse, licensed practical nurse or registered nursing assistant who is not a member of your family, but only if the patient requires the specific skills of a trained nurse You should apply for a assessment before home nursing begins Chronic or convalescent care, provided in a hospital, nursing home or for home nursing care, for a condition where improvement or deterioration is unlikely within the next months months, excluding custodial care Drugs and drug supplies described below when provided in Canada. Benefits for drug expenses outside Canada are payable only as provided under the care provision. Drugs which require the written prescription of a physician or dentist, including oral contraceptives Injectable drugs including vitamins and vitamins, and allergy extracts. Syringes for self-administered injections are also covered Disposable needles for use with insulin injection devices, lancets and test strips Extemporaneous preparations or compounds if one of the ingredients is a covered drug Certain other drugs that do not require a prescription by law may be covered when prescribed by your physician or dentist. If you have any questions, contact your plan administrator before incurring the expense. The plan will also pay for vaccines used to prevent disease For drugs eligible under a provincial drug plan, coverage is limited to the deductible amount and coinsurance you are required to pay under that plan. Rental or, at Life's discretion, purchase of certain medical supplies, appliances and prosthetic devices prescribed by a doctor Custom-made foot orthotics and custom fitted orthopedic shoes, including modifications to orthopedic footwear Hearing aids including repairs, batteries, tubing and ear molds provided at the time of purchase Diabetic supplies: Novolin-pens or similar insulin injection devices using a needle, blood-lettingdevices letting devices including platforms but not lancets. Lancets are covered under prescription drugs Blood-glucose monitoring machines Diagnostic x-rays and lab tests Out-of-hospital treatment of muscle and bone disorders, including diagnostic x-rays, by a licensed chiropractor Out-of-hospital treatment of movement disorders by a licensed physiotherapist Visioncare Glasses and contact lenses required to correct vision when provided by a licensed ophthalmologist, optometrist or optician For information on available discounts on and vision care services, refer to the Preferred Vision PreferredVision Services section of this booklet following the Healthcare benefit. Out-Of-Count Care Emergency care outside Canada is covered if it is required as a result of a medical emergency arising while you or your dependent is temporarily outside Canada for vacation, business or education purposes. To qualify for benefits, you must be covered by the government health plan in your home province.