STUDENT HEALTH PLAN
University of New Brunswick Graduate Student Association
September 1, 2013-August 31, 2014
Extended Health Care (EHC)
Summary of Benefits: Health, Dental, Accident
Prosthetic Appliances (100% Co-insurance)
Prescription Coverage
Direct2U Prescription Delivery
All other Pharmacies
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100% generic
80% generic
80% brand
80% brand
The Dispensing fee is capped at $7.00 per prescription.
Plan will cover up to cost of the lowest priced generic equivalent.
Direct2u Prescriptions will significantly lower your out-of-pocket costs.
For more information, visit www.studentvip.ca/unbgsa/vip_benefits/direct_2u_
prescriptions
Prescription drug coverage is limited to those drugs included in the New Brunswick
Drug Benefit Formulary. Benefits do not include fertility drugs, erectile dysfunction
drugs, smoking cessation aids/remedies, or anti-obesity drugs/products. To see if a
drug is covered, use the Eligible DIN Search at www.studentvip.ca/unbgsa or contact
RWAM.
Maximum $5,000 per insured per benefit year
Extended Practitioner Coverage
(80% Co-insurance)
Maximum $400/benefit year, per practitioner
Chiropractor
Naturopath
Speech Therapist*
Physiotherapist*
Podiatrist
Psychologist* *Physicians’ written prescription must accompany first claim
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Orthotic shoes and Orthotic appliances, prescribed by a medical doctor, an orthopaedic surgeon
or podiatrist (maximum $200/benefit year)
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Medically necessary equipment and supplies, (e.g. casts, splints, trusses, crutches, braces) with
a physician’s prescription.
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Wheelchair repairs (lifetime maximum $250)
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Ambulance to the nearest treating hospital
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Hearing Aids (maximum $500 every 5 years)
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Diabetic Supplies to a maximum of $500/benefit year (insulin syringes, disposable needles for use
with non-disposable injection devices, lancets and test strips)
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Injectable drugs including vitamins and insulins
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Extemporaneous preparations or compounds if one of the ingredients is a covered drug
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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.
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Hepatitis B vaccine, subject to a maximum of $100.00 per insured, per benefit year
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Nuva Ring (contraceptive), subject to a maximum of $144.00 per insured, per benefit year
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Oral contraceptives and the patch (birth control)
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All acne preparations including Accutane
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Preventative vaccines
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Vision Care (100% Co-insurance, maximum $150 every 24 months)
Frames, Lenses, and Contact Lenses, plus one general optometric eye examinations during
any 24 consecutive months.
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Cost of artificial limb when the loss of the limb occurs while the person is insured under this
benefit. Cost of repair is also covered.
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Replacement of artificial limb when required due to physiological change. An application for
pre-approval of the replacement should be submitted to the insurer.
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Charges for artificial eyes, including one polishing or one re-make per benefit year.
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External breast prosthesis, when required due to a total or radical mastectomy which is
performed while insured under this benefit. The cost of up to two surgical brassieres (maximum
$200/benefit year) is included.
Prosthetics Notes: Myoelectric appliances are not covered. it is recommended that an application
for pre-approval of any prosthetic be submitted to the insurer.
Travel Coverage
(Overall maximum $5,000,000)
Emergency Out-Of-Province/Canada (OOP/OOC)
This benefit will provide reimbursement for emergency hospital, surgical, and medical expenses to a
maximum of $5,000,000 outside your Canadian home province of residence or outside Canada as
follows:
Hospital services in a public or general hospital and medical-surgical expenses for services of a
legally qualified physician or surgeon rendered, when the fees for such services are in excess of the
amounts allowed by the applicable Canadian provincial government health plan in which the patient
is a resident.
‘Travel Assist’ Service: While travelling outside your Canadian home province of residence or outside
Canada, ‘Travel Assist’ (a world-wide medical assistance service) will be available if a medical
emergency or other personal emergency occurs. Travel Assist services are available 24 hrs/day, 7
days/week. Travel Assist brochures may be downloaded on-line at www.studentvip.ca/unbgsa
OOC Limitations: Only hospital, surgical or medical services resulting from a medical emergency
while the coverage is in force will be eligible. Coverage is limited to a trip duration not exceeding of
120 days from the date of departure from your province of residence. For students on Study/Work
terms outside Canada, you may apply for an extension around your study/work term not exceeding
60 days, by downloading the form at www.studentvip.ca/unbgsa
Claiming EHC Benefits
For EHC claims requiring reimbursement, the GSA Claim for Extended Health Benefits form may
be downloaded on-line at www.studentvip.ca/unbgsa or obtained from the GSA Student Health
Plan Office.
Save time and paper! Students are encouraged to apply for Direct Deposit of benefit payments
to your personal bank account. The Application for Direct Deposit form can be downloaded
on-line at www.studentvip.ca/unbgsa. Otherwise EHC benefits will be paid by cheque, mailed to
the home address you indicate on the claim form.
To avoid delays in processing your EHC claim, you must ensure that you attach ALL paid-in-full
receipts and that the claim form is fully completed including your Student I.D.#, signed and dated.
Note that instructions on the claim form allow for submission of your claim via e-mail & scan, fax,
or regular mail.
CLAIMS DEADLINE: All claims for EHC expenses incurred must be submitted to RWAM no later
than 90 days after the date your Student EHC coverage terminates, or no later than one year from
the date the expense was incurred, whichever comes first.
STUDENT HEALTH PLAN
University of New Brunswick Graduate Student Association
September 1, 2013-August 31, 2014
Summary of Benefits: Health, Dental, Accident
Limitations and Exclusions to the Dental Plan:
Dental Coverage
Combined Maximum $750/year/insured
Current Dental Fee Guide
Examinations (100%)
Endodontics (10%)
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Complete oral exam (once every 24 mths)
Limited/recall exam (once every 9 mths)
Specific Oral exam (once every 9 mths)
Emergency Oral exam (once every 9 mths)
Pulpectomy
Root canal therapy
Apicectomy/apeal curettage
Retrofilling
Radiographs (100%)
Minor Restorative (75%)
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Complete series (once every 24 yrs)
Periapical (max. 16 films in 36 consecutive mths)
Bitewing (max. 4 films in 9 consecutive mths)
Panoramic (once every 24 mths)
Occlusal (max 4 films in 9 consecutive mths)
Fillings
Caries/trauma control
Retentive pins
Pre-fabricated restorations
Space Maintainers (for children under 12)
Preventative Services (100%)
Extractions (75%)
• Dental polishing (one 15 min. unit every 9 mths)
• Scaling (four 15 minute units every 9 mths)
• Fluoride Treatment (once every 9 mths)
• Removal of erupted teeth, impacted
teeth, residual roots
• Surgical exposure of teeth
• Limited to 2 wisdom teeth/benefit year
Periodontics (10%)
Anaesthesia (80%)
• Scaling in excess of four units in a 12 mth
period (max. 8 units/year)
• Root Planing
• Surgery to treat the soft tissues (gums) &
bone supporting the teeth
If performed in conjunction with insured
surgical services
• General Anaesthesia
• Deep Sedation
• Conscious Sedation
Denture Services (10%)
Major Restorative (10%)
• Repairs, relining, rebasing
• Crowns, Bridgework, Dentures
(subject to limitations)
Dental Accident (100% Co-insurance, $2,000/lifetime maximum)
Charges for required dental treatment performed by a dentist, due to damage to sound, natural
teeth caused by an accident (i.e. solely through violent, external and accidental means) occurring
while insured under this student plan.
A sound tooth is any tooth that did not require restorative treatment immediately before the accident.
A natural tooth is any tooth that has not been artificially replaced. Treatment must start within 90
days after the accident, unless delayed by a medical condition.
No benefits are paid for accidental damage to dentures, orthodontic diagnostic services or
treatment, or dental treatment completed more than 12 months after the accident.
Note: Dental Accidents are covered under the Extended Health Care portion of the plan and should
be claimed using a Health Claim Form.
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Dental Coverage
1. Dental services not shown on the list of eligible expenses.
2. Expenses incurred for procedures or supplies used in Temporomandibular Joint Dysfunction (TMJ) and
treatment rendered for full mouth reconstruction for vertical dimension correction including attrition, or for
prosthetic splinting.
3. Dental services covered by any government agency.
4. Dental services as a result of intentionally self-inflicted injuries (while sane or insane) or as the result of
committing or attempting to commit a criminal offense.
5. Dental treatment for cosmetic purposes.
6. Charges for missed appointments, completion of claim forms, and advice by telephone.
7. Dental treatment required as a result of war (declared or not), military services, or participation in a riot,
insurrection or civil commotion.
8. Expenses incurred for preformed steel or polycarbonate crowns.
9. Any dental treatment which is not yet approved by the Canadian Dental Association, or which is
experimental in nature.
10.Expenses incurred for nutritional counselling, oral hygiene instruction, and dental plaque control programs.
11.Expenses incurred for the replacement of appliances that are lost, mislaid, or stolen.
12.Dental supplies intended for sport use, such as mouth guards.
13.Dental services required due to congenital malformation.
14.Dental services rendered by a relative are excluded.
15.Dental Services incurred outside of Canada.
16.Crowns - the initial installation of a crown, if the crown is necessary to restore cuspal/incisal damage
replacement of an existing crown, if the crown is at least 5 years old.
17.Bridgework - construction and initial installation of a fixed bridge (if 3 or more teeth are missing in the
arch, the insurer reserves the right to base the reimbursement benefit on the lowest cost of alternate
treatment required to adequately correct the condition, regardless of the insured’s choice of treatment);
and replacement of fixed bridgework, if the existing appliance is at least 5 years old and cannot be made
serviceable.
18.Dentures - construction and installation of an initial permanent partial or complete denture and
replacement of an existing partial or complete denture with a permanent denture, if the existing denture
is at least 5 years old and cannot be made serviceable.
Claiming Dental Benefits
In most cases, your dentist can send your dental claim electronically (EDI). This convenient method is
offered by many dentists and is a service supported by RWAM. Present your Pay Direct card with your
Student I.D. and RWAM Group numbers on it. You may also be asked for a Carrier ID or BIN number,
which is #610616 and is printed on your card. (If this service is not provided by your dentist, download a
GSA Dental Claim form at www.studentvip.ca/unbgsa).
Save time and paper! Students are encouraged to apply for Direct Deposit of benefit payments to
your personal bank account. The Application for Direct Deposit form can be downloaded on-line at
Pre-Authorization: It is strongly recommended that you advise www.studentvip.ca/unbgsa. Otherwise Dental benefits will be paid by cheque.
your dentist to submit a pre-authorization form to RWAM with
regards to extensive dental procedures performed. This is to CLAIMS DEADLINE: All claims for Dental expenses incurred must be submitted to RWAM no later than
90 days after the date your Student Dental coverage terminates, or no later than one year from the date
prevent unexpected costs. Especially with a Dental Accident
the expense was incurred, whichever comes first.
STUDENT HEALTH PLAN
University of New Brunswick Graduate Student Association
September 1, 2013-August 31, 2014
Summary of Benefits: Health, Dental, Accident
IMPORTANT! NEW to the GSA Health & Dental plan for 2012-13 - Opt-outs may
be processed online at www.studentvip.ca/unbgsa. Those who opted out in
previous years MUST opt out again.
Note: It is your responsibility to learn about the choices available to you, take appropriate
actions within the given time limits, keep proper records of those actions, and monitor your
student account to ensure it reflects the decisions you made.
When does my coverage begin & end?
For Fall enrolments your benefit year is: September 1, 2013 to August 31, 2014
For Winter enrolments your benefit year is:
January 1, 2014 to August 31, 2014
Who is eligible for coverage?
Full-time graduate students who are under the age of 70 and are registered at UNB Fredericton or
UNB Saint John are automatically enrolled in the plan, and are charged the appropriate premiums
through Financial Services. Part-time students are not enrolled.
Are both Extended Health & Dental mandatory under the Plan?
No, the Dental portion of the plan is optional. The Extended Health portion is mandatory (university
policy) unless the student provides confirmation of alternate comparable coverage and applies to
opt out.
If you opted out last year, you must opt out this year using the online opt out tool or in person at the
GSA Health Plan Office during the fall term opt out period.
Co-ordination of Benefits (COB)
If you remain enrolled in this student health plan in addition to your comparable health coverage,
you may possibly increase your total benefits by claiming Coordination of Benefits (COB) between
the plans. Benefits payable under this student plan will not exceed the combined total amount of
eligible expenses incurred.
Who can opt-out of the Plan?
ONLY students who are already covered under comparable extended health coverage can Optout of the GSA Health Plan. It is university policy that full-time graduate students have Extended
Health Care (EHC) coverage under this plan. Proof of comparable extended health benefits under
another plan is required in order to be eligible to Opt-out.
Because dental coverage is optional under the GSA Health Plan, students may Opt-out of the
dental plan without having comparable dental coverage.
Your provincial coverage under Medicare or any other Canadian province and International Health
Insurance coverage are NOT considered to be comparable health care plans and may not be used
to Opt-out.
Annual opt-out required, even if you opted out in previous years
You must apply to Opt-out each benefit year by the designated Opt-out deadline, for both health
and dental.
(Part-time students are not enrolled and therefore do not need to Opt-out.)
How do I opt-out?
Opt-outs can be processed online at www.studentvip.ca/unbgsa or manually at the GSA Health
Plan Office. You MUST Opt-out of the plan(s) annually each benefit year.
Frequently Asked Questions
Is Family Coverage available for my dependants?
Yes, at additional cost.
New students and returning students may add your spouse/common-law spouse and/or dependent
children by completing the Application for Family Coverage form available on-line at www.studentvip.ca/
unbgsa and submitting it along with your payment to the GSA Health Plan Office by the deadline of
September 20, 2013.
New students starting in the winter term may add family before the deadline of January 24, 2014.
Family coverage CANNOT be added after the above deadlines UNLESS there is a “life change”, i.e.: birth
of a child, marriage. In these instances, students must bring confirmation of the life change to the GSA
Office to complete the application form along with payment of the premium by cash, or cheque payable to
the Graduate Student Association.
Eligible Dependent Spouse as used herein means a person who is a resident of Canada and to whom the
insured student is lawfully married provided there is no legal separation in effect, or a person with whom the
insured student has cohabited for a period of at least 12 consecutive months and who has been publicly
represented as the student’s common-law spouse or partner.
Eligible Dependent Child(ren) as used herein means any unmarried, natural child, step-child or legally
adopted child of the insured student; any unmarried child of the student’s common-law spouse who is
domiciled with the student for at least 12 consecutive months; and any unmarried child for whom the
student is legally and financially responsible. A child must be under age 21 and be a resident of Canada
to be an eligible dependent. However, a child who is age 21 or over and under age 25, may be eligible as
a dependent if they are in full-time attendance at an accredited university, college, or similar institution in
Canada, and they are not engaged in full-time employment. Any child (regardless of age) who is proven
to be suffering from a mental or physical infirmity and as a result of such infirmity is wholly financially
dependent on an insured student can be considered an eligible dependent.
When are opt-outs accepted?
The Opt-out period for the fall term 2013 is from September 1, 2013 to the deadline of September 20, 2013.
The Opt-out period for the winter term 2014 is from January 1, 2014 to the deadline of January 24, 2014 and
is available only for new students enrolled in the winter term.
What if I lose the comparable coverage I had when I opted out?
You must obtain confirmation of the loss of your comparable coverage and enrol under the EHC portion of
the GSA Health Plan within 30 days of the termination date of your comparable coverage.
There will be no exceptions or extensions on this 30 day deadline. If you do not enrol within the 30 day
deadline, you cannot be covered by the GSA Health Plan.
What happens if my status changes? (i.e. full-time to part-time)
Your status as of the Opt-out deadline is your status in the GSA Health Plan for the full benefit year. Should
you receive a retroactive status change from full-time to part-time, you will remain in the plan and are
responsible for the related fees for the full benefit year.
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Note:
There are no exceptions or extensions to the Opt-Out deadline.
You will need information from your comparable plan to complete the application to
Opt-Out.
STUDENT HEALTH PLAN
University of New Brunswick Graduate Student Association
September 1, 2013-August 31, 2014
Summary of Benefits: Health, Dental, Accident
Additional Information
What is the cost of the Health Plan?
Student Rates (Single Coverage)
Family Rates
Fall
Winter
Spring
Fall
Winter
Spring
Health
$265.00
$180.00
$135.00
$485.00
$320.00
$250.00
Dental
$200.00
$200.00
$200.00
$370.00
$245.00
$245.00
What is the difference between the GSA Health Plan & New Brunswick Medicare or International Insurance?
Provincial coverage, Medicare in New Brunswick, and International Health Insurance: Examples of eligible expenses include hospital stays, blood work,
x-rays, doctor appointments.
Under the GSA Health Plan: Examples of eligible expenses include prescription drugs, some vaccinations, vision care, chiropractor and physiotherapy.
Where do I go for International insurance information?
The international insurance plan is administered by Financial Services : www.unb.ca/financialservices/students/healthinsurance.html
How do I obtain my pay direct benefit card?
Pay Direct benefit cards will also be available for pick up at the GSA Health Plan Office.
Meanwhile, your Pay Direct benefit card is in printable format at www.studentvip.ca/unbgsa. You must indicate on the card Student ID# in the space provided.
Providers
Extended Health & Dental Plan underwritten by:
Travel Assist serviced and administered by
Extended Health & Dental Plan administered by
UNB GSA Student Health Plan arranged by
LA CAPITALE INSURANCE & FINANCIAL SERVICES INC.
ALLIANZ GLOBAL ASSISTANCE
RWAM INSURANCE ADMINISTRATORS INC. Group #490015
C & C INSURANCE for STUDENT VIP
Visit or Contact the UNB GSA Health Plan Office at:
The Alden Nowlan House (“Grad House”)
676 Windsor St., 2nd floor
Fredericton, NB E3B 5A3
(behind Fredericton Campus bookstore)
Phone: 506-453-4700 E-mail: gsa@unb.ca
GSA Health Plan Administrator: Jeff Mott
Office Hours: Monday to Friday, 9:00am-1:00pm
www.unbgsa.ca
University of New Brunswick and
the University of New Brunswick
Graduate Student Association are
committed to protecting the privacy,
confidentiality, accuracy and security
of personal information it collects,
uses, retains or exchanges in the
necessary conduct of our business.
Notes:
• Canadian students who are not residents of New Brunswick are solely responsible for determining how they use
their own home province’s health insurance plan while studying at University of New Brunswick.
• In the event of any discrepancy between this document and the master policy or plan text, the applicable master
policy or text will govern.