Benefit Plan

Frequently Asked Questions – Extended Health Care

Essential info

Insured with Great-West Life Assurance Company
Policy No. 335645 – Division 10
Toll free number:
1-800-957-9777
(Select prompt 1 for language preference = English)
(Select prompt 4 for benefit selection = Extended Health inquires)

This site is for general information purposes only and is not intended to provide you with any personalized financial, insurance, legal, accounting, tax, medical or other professional advice. You cannot rely on this site as a substitute for independent research or for personal advice from a representative of the CISVA or any other appropriate professional or medical advisor.You must contact Great-West Life directly to confirm eligibility for any and all eligible benefits under the Extended Healthcare Policy. (Sept. 26/07)

General


Which employees are eligible for coverage under the CISVA, Extended Healthcare Plan?

The eligibility requirements are as follows as defined in our Group Policy Contract:

1. You must be an Insurable Employee
2. You must be Actively at Work
3. You must be in the appropriate Benefit Class

Please refer to the Definitions and General Terms section of your benefit booklet for further clarification. Further details on the Benefit Class structure can be found on the CISVA website: CISVA Benefit Plan Overview / Basic Elements of Our Plan

What general expenses are covered in our Extended Health plan?

Please refer to the Booklets section of the CISVA website. The available booklets are reflective of the appropriate Benefit Class that pertains to you. Extended Healthcare benefits are detailed according to your class status. Please ensure that you are referring to the correct benefit booklet.

How much of our health costs are paid by our plan?

In-Canada expenses = 80% of eligible expenses, up to any benefit plan maximums. There is a $25.00 annual employee/family deductible that must be satisfied prior to reimbursement.

Out-of-Country, unforeseen expenses = 100% of eligible expenses up to the specified benefit plan maximum that is reflective of your benefit class.

The annual deductible is not applied to any Out-of-Country expenses.

Please refer to your benefit booklet for any annual maximums that may apply for a particular benefit. If there is no financial limit set on a particular benefit, then Great-West Life will reimburse eligible expenses up to the reasonable & customary charge.

What are Reasonable & Customary (R&C) charges?

Most benefit plans include coverage for Reasonable and Customary charges for dental and medical services. Generally this is the lowest of the following:

  • Representative pricing in the area where the treatment is provided.
  • Prices shown in the applicable professional association fee guide and the maximum prices established by law.

What is Coordination of Benefits?

When two or more plans are involved, one plan is considered to be the primary plan and the carrier of that plan is the primary carrier (or insurer). The primary carrier pays its eligible amount first. The secondary carrier then reduces its payment by the amount by which total payments would exceed eligible expenses available through both plans. Eligible expenses are as defined in each carrier’s contract before limitations like your annual deductible, co-insurance, fee guides, and maximums are applied.

As a plan member your claims should be processed through your benefit plan first. Claims for your spouse must be processed through your spouse’s plan first. Any remaining balance can then be processed through the other insurance plan.

When a child is covered under both parents’ plans, the plan of the parent whose birthday (month and day) falls earlier in the calendar year is billed first.

Drugs


How do I know if a prescription from my doctor is covered by our plan?

There is provision for various prescription drugs which legally require a prescription when prescribed by a physician, dentist, Nurse Practitioner or Pharmacist. The legally prescribed drug(s) must have a Drug Identification Number (DIN).

Prescribed drugs purchased over-the-counter are not eligible for reimbursement!

IMPORTANT: Please contact Great-West Life directly to confirm if coverage is available for your legally prescribed drug.

Prior Authorization Drugs

Certain prescription drug claims need to be approved by Great-West Life before they can be considered for reimbursement. The Prior Authorization process helps Great-Wets Life ensure that appropriate drug coverage is provided, and that prescribed drugs are considered reasonable treatment for your condition.

If you want to be considered for coverage for one of the drugs listed below, you must contact Great-West Life and request the Request for Information form for the appropriate drug. Send the form to Great-West before, or along with, your first claim for the drug to be reviewed.

• Alertec/Xyrem • Amevive/Raptiva
• Botox/Myobloc • Cerezyme
• Enbrel • Flolan/Remodulin/Revatio/Tracleer/Thelin
• Fludara/Fludarabine • Forteo
• Gleevec • Growth Hormones (Humatrope/Nutropin/Genotropin/Protropin/Saizen)
• Herceptin • Humira
• Iressa • Kineret/Orencia
• Myozyme • Oncology drugs (Avastin/Erbitux/Camptosar/Irinotecan Hydrochloride/Velcade/Taxotere/Alimta/Mabcampath/Nexavar/Abraxane/Femara/
Sprycel/Sutent/Temodal)
• Pulmozyme • Remicade
• Replagal/Fabrazyme • Rituxan
• Sativex • Sensipar
• Serostim • Somavert
• Tarceva • Thyrogen
• Tysabri • Xolair
• Zavesca


Where do I submit my eligible prescription drug claims?

All eligible prescription drug claims will be processed by Assure.

The Assure Card is an electronic payment system that provides on-the-spot claims submission of prescription drug claims at almost any pharmacy in Canada. It’s a convenient, easy-to-use alternative to submitting claim forms. Plan members continue to pay 100% of the drug costs upfront; however, you simply present your Assure Card when having prescriptions filled. The pharmacist uses the card to confirm eligibility, drug coverage and remit your eligible drug claim directly to Assure for processing.

If/when a manual claim is required, please complete the attached claim form. Please note that you continue to use the same policy number (335645) and 9-digit identification number as your other extended health claims.

All other extended health claims will continue to be assessed directly by GWL.

Medical Equipment & Out-of-Country Coverage


Pre-determination of Benefits:

There are times in which you may be in a position which requires you to purchase an expensive item – ie: a wheelchair, CPAP machine, prosthetic devices, etc. For items in excess of $500, Great-West Life may coordinate your claim directly with the service provider. In order for this to be accomplished, a pre-determination of benefits (pre-authorization) must be established.

This is a process that occurs before any services are performed, in which the provider outlines a proposed course of treatment and estimated costs. Great-West Life will then specify the dollar amount and services that would be considered, if covered, by the CISVA Extended Healthcare plan. Great-West Life requires the following information when submitting a pre-determination of benefits:

  1. letter from the doctor outlining diagnosis & prognosis, confirming necessity for the specified equipment;
  2. estimate from the service provider detailing the required equipment and applicable costs;
  3. a note from yourself (the employee) confirming and authorizing Great-West Life to coordinate the claim directly with the service provider; therefore, reimbursing them directly;
  4. Extended Health claim form must be attached. Please indicate that this is a pre-determination which is why there will not be a purchase date on the invoice.

Take a photocopy for your own records and forward all originals to Great-West Life for review.

Are special exams e.g. MRI or CatScan or PetScan covered?

No. Great-West life will not cover services or supplies that are covered by the government plan in the insured person’s home province.

Wigs

Coverage is provided for wigs for permanent hair loss as a result of any injury or disease, or for temporary hair loss as a result of medical treatment for any disease. Benefits are available following chemotherapy or radiation treatment or for total hair loss from Alopecia Totalis (please refer to the Medical services and equipment section of your benefit booklet for plan maximums). However, Great-West Life will allow coverage of wigs for other medical conditions as well. Please refer to the following conditions that are covered:

  • Alopecia Totalis
  • Alopecia – areata, congenitalis, leprotica, medicamentosa, neurotica, scarring alopecia
  • Burns
  • Cancer – chemotherapy
  • Lupus
  • Psuedopelade Broque – form of Alopecia Areata
  • Schleroderma

Do I need to get travel insurance when I go outside of B.C. – or outside of Canada?

No, you don’t if you are an eligible employee within Benefit Class 1, 2, 4 or 8. Our Extended Healthcare plan provides 100% coverage for various emergency & unforeseen medical expenses up to $1 million dollar for each insured person for all the eligible covered costs related to any one emergency.

Yes, you do if you are an eligible employee within Benefit Class 3 . Although the reimbursement level for these types of eligible expenses continues to be reimbursed at 100%, the benefit maximum is cut-back to a  maximum of $10,000 per insured individual.

Yes, you do if you are an eligible employee within Benefit Class 5 . Although the reimbursement level for these types of eligible expenses continues to be reimbursed at 100%, the benefit maximum is cut-back a maximum of $500,000 per insured individual.

Note: Each adult traveling should be carrying a Travel Assist booklet, which provides the toll free telephone contact to direct payment to the medical provider anywhere in the world. The employee’s name, group policy number (No. 335645) and identification numbers are to be written on the back cover. A PDF copy of this booklet can be located within the Booklets section of the CISVA website.

Important: You must contact the Great-West Life Out-of-Country department to verify any coverage that is in place for this benefit. Please call them directly from 6:00am – 3:00pm (Pacific Standard Time) at 1-800-957-9777.

Paramedicals (Physiotherapy, Massage therapy, etc…)


Overview & financial benefit breakdown

Where provincial registration exists, the paramedical practitioner must be registered in the province where the service is given. If the practitioner is not registered with the applicable governing authority, then your claim will be rejected accordingly.

For your reference, we have included the applicable breakdown of expenses per covered benefit as confirmed by Great-West Life (as of February 2, 2017). Please note that eligible expenses are not to exceed the maximum payable amount listed within the Calendar Year Maximum.

Paramedical Practitioner

R & C Charges
(total amount payable is NOT to exceed Calendar Yr. Max)

Calendar Year Max.
(per covered person)

Acupuncturist $80.00/hr

$500.00

Chiropodists or Podiatrists $90.00/hr
x-ray $80.00
surgery $500.00

$500.00

Chiropractor $60.00/hr
x-ray $80.00 

$500.00

Massage Therapy $115.00/hr

$500.00

Naturopath $145.00/hr

$500.00

Osteopaths $130.00/hr
x-ray $80.00

$500.00

Physiotherapy $85.00/hr

$500.00

Psychology $200.00/hr
Testing $800.00

$1,000.00

Speech therapy $160.00/hr

$1,000.00

Resource information for confirming Paramedical practitioner’s designations

Physiotherapy Association of BC
Phone: (604) 736-5130
Fax: (604) 736-5606
www.bcphysio.org

Massage Therapists Association of BC
Phone: (604) 873-4467
Fax: (604) 873-6211
www.massagetherapy.bc.ca

College of Psychologists of BC
Phone: (604) 736-6164
www.collegeofpsychologists.bc.ca 

College of Naturopathic Physicians of BC
Phone: (604) 688-8236
www.cnpbc.bc.ca

BC Chiropractic Association and BC College of Chiropractors
Phone: (604) 270-1332
Fax: (604) 278-0093
www.bcchiro.com

British Columbia Association of Speech Language Pathologist & Audiologist
Phone: (604) 420-2222
Fax: (604) 736-5606
www.bcaslpa.ca

College of Traditional Chinese Medicine Practitioners and Acupuncturists of BC
Phone: (604) 738-7100
Fax: (604) 738-7171
www.ctcma.bc.ca

Is a referral from a doctor required for use of physiotherapy, massage, acupuncture, etc., treatments?

If you are a resident of British Columbia, no, you do not require a referral from your doctor. The doctor’s referral was a requirement that had to be met for MSP as they had previously covered a portion of the user fees. However, since these expenses are no longer covered by MSP, Great-West Life has not enforced this requirement to supply a referral from your doctor (again, providing that you are a BC resident).

Please note that the invoice provided by your paramedical practitioner’s office must indicate the following:

  • The name of the claimant

  • Date the service was rendered and that the expense was paid in full

  • Receipt must reflect practitioner’s designation (qualification) and their registration number

  • Address of paramedical practitioner’s office

Claim submissions


Where do I mail my claims to?

Send to:
Great-West Life Assurance Co.
PO Box 4408
Regina, SK S4P 3W7

Please note that you also have the option of submitting your claims electronically to GWL via GWL’s E-Claims (aka: Member Portal).
Is there a claiming deadline for submitting my claims?

Yes. Great-West Life must receive proof of claim no later than June 30th of the year following the date that you incurred your expense.

Example: you purchased a custom-made orthotic for yourself in August 2007. You have until June 30, 2008 for Great-West Life to have received your claim.

Confirmation of this deadline will be found in the tail-end section of the Extended Healthcare portion of your benefit booklet under the section entitled, Submitting a claim.

Can my claims be sent directly to Great-West Life Assurance?

Generally, the answer is no. Our Extended Healthcare plan has been created as a reimbursement policy only. Therefore, you pay the initial expense upfront and Great-West Life will assess your claim accordingly.

In those cases where a pre-determination has been submitted and approved by Great-West Life in advance, then your service provider can coordinate payment directly with Great-West Life on your behalf.

Where can I get blank claim forms?

The following 3 methods are ways in which you can obtain a Healthcare Expense Statement claim form:

  1. On the CISVA website, refer to the Forms / Claim forms section. This document already includes the plan name, plan number and division number.
    1. Select Extended Health Care
    2. Open the document and complete accordingly
  2. Log onto the Great-West Life GroupNet for Members: http://groupnet.greatwestlife.com
    1. If you have not already done so, please register yourself as a new user
    2. Select Form & Cards from the toolbar
    3. Double-click on Claim forms. The claim form is pre-populated therefore all of your personal information will automatically download onto your claim form.
  3. Log onto Great-West Life’s website: www.greatwestlife.com
    1. On the left-side of the page, refer to Clients & Plan Members
      1. Select Client Services
    2. Select GO under A group benefits plan member?
    3. Select Forms from Basic Forms & Resources
    4. Double-click on the first bullet called, Standard claim forms
    5. Select second bullet called, Healthcare Claim Form (M635D)
      1. Complete the form accordingly

Regardless of which method you use to obtain a claim form, please ensure that you copy every claim before sending it to Great-West Life. Original documents are always sent to the insurance carrier. Please ensure that receipts are stapled to the back of your claim form.

What can I do if I disagree with the amounts paid for my claims, or some claims are declined?

Contact the Great-West Life Benefit Payment Office (BPO) directly at 1-800-957-9777 to review the assessment of your claim. If still unsatisfied, send the original claim copy, plus the “Explanation of Benefits” that shows amounts paid and reasons, with your reason for disagreement to my office. I will assist you in investigating the matter further.

What is Member Portal? (Accessing your benefits any time)

Access for your group benefits information has never been easier with Great-West Life’s GroupNet for Plan Members (aka: Member Portal).

Register once and you’ll connect to a world of secure, user-friendly services – available online, any time! Available features are as follows:

  • Sign up for direct deposit claim payments – claim paid directly into your bank account
  • Access expanded coverage information quickly and easily
  • View your claim status and Explanation of Benefits for the past 24 months
  • Check your Extended Healthcare balance and the date that you would next be eligible for a particular benefit
  • Check when you’re covered for new glasses or contacts
  • Complete and print personalized claim forms
  • Access the Health & Wellness Site that includes:
    • In-depth information on diseases, conditions, drugs and treatment options
    • Interactive health and wellness tools, including the Personal Health Risk Assessment

Registration is simple and secure.

Follow these easy steps to register and log in for the first time:

  1. visit http://groupnet.greatwestlife.com
  2. have the following information ready:
    1. Plan number (No. 335645) and your employee Identification number (available on the front of your last benefit statement or on your wallet certificate – little green card)
    2. Your date of birth
    3. Date of birth of one of your dependents (if applicable)
    4. Your postal code
    5. Your e-mail address
  3. follow the registration instructions to choose your own user name and password (do not include your middle name)

Registration will be confirmed in writing by posted mail. Sign up once and return any time. All you need to remember is the personalized password and user name you’ve selected!

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