Your PPAO
Medical
Benefits Plan
Plan overview
As a member of the PPAO you are entitled to enrol yourself
and your family in a comprehensive and competitively priced
Extended Health Care (EHC) Insurance benefits plan. EHC
coverage helps cover a number of important medical expenses
that may not be paid by provincial health plans, helping you
manage the cost of maintaining good health and allowing you
to be worry free and enjoy your retirement to the fullest.
What is Extended Health Care
Insurance for Retirees?
Extended Health Care Insurance for Retirees provides you with insurance
coverage for a range of health care expenses during your retirement.
my drug card
The plan provides a convenient drug card for
your prescription needs.
Drug card not available to residents of Quebec.
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What is included in the insurance plan?
You have a choice between two plan types:
1. Standard Extended Health Care Insurance for Retirees
2. Enhanced Extended Health Care Insurance for Retirees
(includes Dental, out-of-province and out-of-country travel coverage)
Coverage for you and your family
You’re not the only one eligible for coverage! You can add your spouse*
and/or dependent children** to your Extended Health Care Insurance for
Retirees plan. Your spouse could apply for coverage even if you don’t.
Eligibility
Enrol without providing proof of good health
You’re eligible to enrol without proof of good health:
if you apply within 60 days from the date your Employer Group Health
Benefit coverage ends.
at any time or within 60 days of your group coverage ending, if you
are actively covered for health benefits under another group plan.
at any time while covered by an employer sponsored Health Spending
Account, or within 60 days of the Health Spending Account ending.
Your Health Spending Account may also allow you to use your account
balance towards the premiums of the Sun Life/PPAO Extended Health.
if you are a spouse of a PPAO retired member.***
Your application must be received at or within 60 days from the date
your group coverage ends to avoid interruptions to your extended health
care coverage.
Enrol with proof of good health
Proof of good health will be required and applies to you and your
spouse when enrolling after the 60-day enrolment period or when
you’re applying without prior group coverage.
* Spouse means your spouse by marriage or a person of the same or opposite sex with whom you have
been cohabiting for at least one year and who is represented publicly as your spouse.
** Your children and your spouse’s children (other than foster children) are eligible dependents if they
are not married or in any other formal union recognized by law, and are under age 19. If your child is
a full-time student attending an educational institution recognized under the Income Tax Act (Canada),
they are considered an eligible dependent until the age of 25 (age of 26 for individuals residing in
Quebec) as long as the child is entirely dependent on you for financial support.
*** Spouses of PPAO retired members who are no longer covered due to an age termination clause
in their group sponsored program may enrol in the PPAO Sun Life plan within 60 days of their health
benefits coverage ending without the requirement to provide proof of good health.
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Coverage Details
Here is an overview of your plan options:
Please note: unless otherwise stated, all maximums are per insured
person per plan year.
plan options
standard
enhanced
Eligible expense limits
$100,000
$250,000 for all benefits
other than Emergency
Medical Care OOP/
OOC (out of province/
out of country) + Travel
Assistance, which is
covered up to $1 million.
Maximum for
prescription drugs*
$1,000
$2,000
Dispensing fees*
Full, up to a reasonable
and customary limit
Full, up to a reasonable
and customary limit
Drugs co-insurance*
80%
80%
Drugs covered
Costs of drugs or supplies
that are prescribed in writing
by a dentist or physician
and are obtained from a
pharmacist are covered
Costs of drugs or supplies
that are prescribed in writing
by a dentist or physician
and are obtained from a
pharmacist are covered
Vision
80% co-insurance, maximum
$150 every two years
Includes: contact lenses, eye
glasses or laser eye surgery
80% co-insurance, maximum
$200 every two years.
Includes: eye exam, contact
lenses, eye glasses or laser
eye surgery
Eye examination
Not covered
Up to $30 for optometrist
fees every two plan years.
Lifetime maximum
Drugs
Vision care
Paramedical services
Paramedical services
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Psychologist
$300 per practitioner, up to
a maximum of $500 for all
services combined.
Includes: physiotherapist,
chiropractor*, osteopath*,
podiatrist*, naturopath,
chiropodist*, registered
massage therapist, &
speech therapist
$300 per practitioner, up to
a maximum of $650 for all
services combined.
Includes: physiotherapist,
chiropractor*, osteopath*,
podiatrist*, naturopath,
chiropodist*, registered
massage therapist, &
speech therapist
*1 x-ray per year
*1 x-ray per year
$60 per visit, maximum
seven visits per plan year
$60 per visit, maximum ten
visits per plan year
plan options
standard
enhanced
Semi-private hospital (in Canada)
Semi-private hospital
80% during the first 30
days, 50% of the balance
to a maximum of $5,000
80% during the first 30
days, 50% of the balance to
a maximum of $10,000
Convalescent hospital
$20 per day, for a maximum
of 180 days. Not custodial.
$20 per day, for a maximum
of 180 days. Not custodial.
Medical services and equipment
Ambulance (in Canada)
Unlimited ground
ambulance
Unlimited ground ambulance.
Air ambulance to a
maximum of $5,000
per instance
Private duty nursing
$5,000 ($25,000 lifetime
maximum)
$5,000 ($25,000 lifetime
maximum)
Accidental dental
$5,000 lifetime maximum
$5,000 lifetime maximum
Hearing aids
$350 every 5 plan years
$500 every 5 plan years
Orthopedic shoes
& supplies
Orthopedic shoes &
orthopedic alterations
& orthotics
maximum $200
(prescription required)
Orthopedic shoes &
orthopedic alterations
& orthotics
maximum $200
(prescription required)
Medical services
& equipment
(maximum per plan year)
$2,500 per insured person per
plan year for all expenses listed
in this category
• Diagnostic services:
Reasonable and customary
• Casts, splints, trusses, braces
or crutches: $300
• Wigs following chemotherapy:
$350 lifetime maximum
• Breast prosthesis: $200
• Other: Reasonable and
customary and up to plan
maximums for artificial limbs
and eyes; stockings; surgical
brassieres; intraocular lenses
following cataract surgery;
stump socks; radiotherapy
or coagulotherapy; oxygen,
plasma and blood transfusion
$5,000 per insured person per
plan year for all expenses listed
in this category
• Diagnostic services:
Reasonable and customary
• Casts, splints, trusses, braces
or crutches: $500
• Wigs following chemotherapy:
$500 lifetime maximum
• Breast prosthesis: $200
• Other: Reasonable and
customary and up to plan
maximums for artificial limbs
and eyes; stockings; surgical
brassieres; intraocular lenses
following cataract surgery;
stump socks; radiotherapy
or coagulotherapy; oxygen,
plasma and blood transfusion
Durable equipment
$2,500 per insured per
plan year
Wheelchair:
$4,000 lifetime maximum
(with some restrictions)
Hospital beds:
$1,500 per lifetime
$2,500 per insured per
plan year
Wheelchair:
$4,000 lifetime maximum
(with some restrictions)
Hospital beds:
$1,500 per lifetime
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plan options
standard
enhanced
Emergency medical out-of-province/country coverage
Emergency medical
out-of-province/
country coverage
Not covered
Emergency medical
expenses covered during
the first 60 days of travel
if the insured is under age
80, and subject to a sixmonth pre-existing medical
condition† limitation.
If you have a pre-existing
medical condition that
existed during the six
months prior to your
trip expenses related
to this condition may
not be covered.
Not covered
80%, diagnostic and
preventative dental
procedures (oral examination,
oral hygiene instructions,
fluoride treatment, scaling
and polishing)
50%, Basic dental
procedures (filling, removal
of teeth, oral surgery, minor
restoration, endodontics
and periodontics)
Maximum of $750 in the
first plan year of coverage,
maximum of $1,000 per plan
year in subsequent years.
Dental Care
Dental coverage
*This plan is second payor to any government – sponsored drug plan. In Quebec, this plan will be second payor to
comply with RAMQ legislation.
†
A pre-existing medical condition is an injury, illness, disease or symptoms which appeared, worsened or required
medical attention, hospitalization or changes in treatment (including changes in medication or dosage) within the
6 months before travelling outside of your province of residence. Sun Life Financial may require medical evidence,
from the attending physician, indicating that the insured person’s medical condition was stable during the 6-month
period before the insured person travelled outside of the province where the insured person resides.“Stable” means
that a recurrence or worsening of the existing medical condition or any problems related to that condition was
not expected while the insured person travelled outside the province of residence. Stability will not be affected by
dosage changes to the following drugs: statins, warfarin, coumadin, insulin, and thyroxine. If the insured person
start or stop these medications, it would be considered a change in medication that would affect their stability.
If blood pressure medication changes, a 3-month stability period is required. If the insured person start or stop
these medications, it would be considered a change in medication that would affect their stability and revert
back to the 6-month stability requirement.
Coverage is subject to certain exclusions and limitations which are described in the individual policy issued to plan
members.To be eligible for this plan, insured members must be insured under their provincial health care plan.
What if I am a resident of Quebec?
If you are a resident of Quebec and over the age of 65 years, you are
required to have Régie de l’Assurance Maladie du Quebec (RAMQ) or an
equivalent group/professional association plan, which is the first payor
for your prescription drugs.
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Applying is easy!
If you apply within the 60-day open enrolment period you
will not be required to provide proof of good health.
How to apply for the 60-day open enrolment period for you
and your family:
1. C
omplete all sections of the enclosed Enrolment/Application
form, with the exception of section 5 and 8.
2. Return the completed form in the enclosed envelope
before your enrolment deadline date.
Once your Enrolment/Application form is processed, you will
receive a welcome package containing your policy, billing
statement and drug card (not available to residents of Quebec).
What happens if I miss the 60-day
open enrolment period?
You can still apply for Extended Health Care Insurance for Retirees for
you, your spouse and your dependent children, but proof of good health
will be required for all applicants. To apply:
1. Complete all sections of the enclosed Enrolment/Application Form.
2. Return the completed Enrolment/Application Form in the enclosed
postage-paid envelope.
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Frequently asked
questions
When will the coverage begin?
Your coverage will begin on the date your Enrolment/Application form
is approved!
How much does Extended Health Care
Insurance for Retirees cost?
The good news is that maintaining your healthcare regime is very affordable.
Your monthly premiums are based on your age as of January 1st of each
year and the province you live in. A full list of rates applicable to your
province of residence can be found on the rate sheet included in this kit.
Premiums are paid on the first of each month. If your Enrolment/ Application
form is approved on the 1st of the month, premiums will be charged for that
month. If your Enrolment/Application form is approved after the 1st, your
premiums will begin on the 1st of the following month.
stretching my money
If you have other coverage that includes a health spending account,
you may be able to claim the premiums you pay for this insurance plan.
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What is not covered by this plan?
Extended Health Care Insurance for Retirees
will not reimburse expenses resulting from:
declared or undeclared war, insurrection, or rebellion;
voluntary participation in a riot or act of civil disobedience;
intentionally self-inflicted injury while sane or self-inflicted injury while insane;
committing or attempting to commit a criminal offence;
services or supplies not specifically listed‡;
missed or cancelled appointments;
examinations or services required solely for the use of a third party;
travel to and from appointments;
experimental services or supplies;
services for which you would not normally have been charged or are not
legally obliged to pay;
over the counter drugs, anti-obesity drugs, experimental drugs, fertility
drugs, dietary aids, vitamins, smoking cessation products and erectile
dysfunction drugs;
acupuncture;
items for personal comfort or for use in connection with sports or other
recreational activities;
costs related to temporomandibular joint dysfunction;
services or supplies available under Workers Compensation Board/
Workplace Safety and Insurance Board;
Emergency Out of Province/Country expenses (including Travel Assistance)
for any insured person age 80 years and over; and/or
any other exclusions or limitations specifically listed in the Extended Health
Care Insurance for Retirees policy.
This plan will not reimburse expenses for services or supplies payable in
whole or in part under any government-sponsored plan or program, except for
user fees, extra billing, and other expenses in excess of those payable under
the government-sponsored plan or program, if the legislation allows their
payment under private plans.
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Please refer to the policy for the complete list of coverage under this category
‡
details of my coverage
Full details of coverage and benefits, conditions,
limitations and exclusions are described in your policy.
Dental coverage included in the Enhanced Extended
Health Care Insurance for Retirees plan will not
reimburse expenses resulting from:
procedures performed primarily to improve appearance;
the replacement of dental appliances that are lost, misplaced or stolen;
missed or cancelled appointments;
completion of claim forms;
services or supplies for which no charge would have been made in the
absence of this coverage;
supplies usually intended for sport or home use (e.g. mouth guards);
procedures or supplies used in full mouth reconstruction (capping all
of the teeth in the mouth), vertical dimension corrections (changing
the way the teeth meet) including attrition (worn down teeth), alteration
or restoration of occlusion (building up and restoring the bite), or for
the purpose of prosthetic splinting (capping teeth and joining teeth
together to provide additional support);
implants and transplants, and repositioning of the jaw;
experimental treatments;
dental services required due to congenital malformation;
declared or undeclared war, insurrection, or rebellion;
participation in a criminal offence; and/or
any other exclusions or limitations that are specifically listed in the
Enhanced Extended Health Care Insurance for Retirees policy.
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making payments is easy
Pay by monthly pre-authorized cheque withdrawals or by credit
card. This will leave you free to travel and enjoy your hobbies
and activities without worrying about missing a payment.
When will the coverage end?
Your coverage will terminate on the earliest of:
the premium due date, subject to the 31-day grace period, for
non-payment of premiums;
the 1st of the month coincident with or next following notification to
Sun Life Assurance Company of Canada of the termination of the policy;
the date you are no longer a resident of Canada;
the date you are no longer covered by a provincial or territorial
government health care plan;
the date of your death.
Spousal and/or Dependent child coverage will
terminate on the earliest of:
the date your eligible spouse and/or dependent child no longer satisfies
the required definition;
the date your spouse and/or dependent child is no longer a resident
of Canada;
the date your spouse and/or dependent child is no longer covered by
a provincial or territorial government health care plan;
the date your coverage lapses, expires or otherwise terminates.
Please note: Your spouse/dependent children can apply to transfer their coverage to a new policy
(without providing proof of good health) if their coverage ends other than by their request. Your spouse/
dependent children can simply contact Sun Life Assurance Company of Canada at the number listed on
the Questions page (within 30 days) to request the appropriate continuance forms. Once the forms have
been completed and processed, a new policy will be issued under the applicant’s name.
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Questions?
If you have questions about Extended Health Care Insurance
for Retirees, call 1-800-669-7921, or if you reside in Toronto,
please call 416-408-7390.
If you are interested in speaking with an advisor regarding your
health care planning, please contact:
Mike Kelly, CFP, CHS, Sun Life Advisor
Local: 519-542-7779 ext. 2213
Toll-free: 1-866-282-3924 ext. 2213
email: mike.f.kelly@sunlife.com
This brochure provides the highlights but not all the details of Extended Health Care Insurance for
Retirees. The complete terms, conditions, exclusions and limitations governing the coverage are found in
the insurance policy 50134 issued by Sun Life Assurance Company of Canada, a member of the Sun Life
Financial group of companies.
Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.
© Sun Life Assurance Company of Canada, 2013.
AA-00104-E 06-13 (PPAO EHC Brochure)