Health & Dental
Plan Guide

Your benefits, as described below, come into effect after any Provincial Health Care annual maximums have been exhausted. Unused benefits from a specified time frame cannot be utilized in a future period.

Covered charges are reasonable and customary expenses needed for medical care, services or supplies, and received while the person is eligible, for either an illness or injury that is non-occupational or related to pregnancy. No amount will be payable for taxes and/or shipping and handling fees for any covered service/product(s).

Charges for dental services by a licensed dentist for the repair of sound natural teeth (healthy, non- diseased and not heavily restored) are covered at 100%, up to reasonable and customary charges, when required for a non-occupational accidental injury, external to the mouth, which occurs while the person is covered. No amount will be payable for injury caused by an object placed in or on the mouth, self-inflicted injury, or damage to existing dentures, crowns, or bridgework. Work performed outside of Canada may be considered, after submitted to any Medical or Travel insurances of which you are eligible.

Benefits shall be paid in accordance with the Ontario Dental Fee Guide for General Practitioners, in effect at the time of treatment. Treatment must commence within 90 days following the date of the accident, and the care or services must be completed within one year from such date. No amount shall be payable for charges incurred after the termination date, or after the person’s coverage terminates.

When submitting a claim for accidental dental, you are required to submit a letter detailing when and how the accident happened. The attending dentist must confirm that the treatment is the result of an accident.

It is recommended that the dentist submit a predetermination outlining the course of treatment and the resulting cost. Eligible accidental dental claims must first be submitted to the Health Care Plan. Once this benefit is exhausted, remaining expenses can then be considered under the Dental Care Plan.

This benefit is underwritten by Chubb Life Insurance Company of Canada under Policy Number SG102526

This coverage applies to the insured student only. The amount of the benefit is limited to the percentage shown in the Schedule of Losses. To see complete details of coverage, or to download your copy of the Accidental Death and Dismemberment Policy, please visit your Plan Member Portal macgsa.drawbridge.ca, or studentbenefits.ca.

When you register an account on your Plan Member Portal, you can visit the Document Centre to fill out the form. Send a scanned copy, or the original signed copy, to The PBAS Group. If a beneficiary is not designated, any payments will be made to your estate.

Charges for licensed ambulance services within Canada, in excess of the amount payable under the covered person’s Provincial Health Care Plan, are covered at 100%, up to $200 per trip.

The coverage includes the transport of the covered person from the place of debilitation to the nearest hospital where treatment is available, or from the first hospital to another for specialized treatment not available at the first hospital, or to a convalescent/rehabilitation hospital. No amount will be paid for air ambulance, or for expenses outside of Canada.

Counselling services provided by a:

• Licensed Psychologist;
• Registered Social Worker/Master of Social Work;
• Licensed Professional Counsellor;
• Licensed Counselling Therapist; or,
• Psychotherapist;

are covered at 100%, up to $400 per benefit year, provided the counsellor is licensed under the appropriate provincial or federal organization to practice their profession, in accordance with the rules of their profession. No amount will be paid for group counselling, testing/assessments, or reports.

Charges for Lab tests performed in a commercial lab, used to diagnose an illness are covered within Canada at 100%, up to reasonable and customary charges, in excess of the amount payable under the covered person’s provincial health care plan, when prescribed by a doctor. Physician and administration fees aren't covered.

Services provided by the following health practitioners are covered, provided the practitioner is licensed by the appropriate provincial or federal organization to practice their profession, in accordance with the rules of their profession:

$35 per visit up to $500 per benefit year:

• Chiropractor

$40 per visit up to $500 per benefit year:

• Physiotherapist (referral required)

$25 per visit, up to $500 per benefit year:

• Massage Therapist (referral required)

$25 per visit, up to $300 per benefit year, per practitioner:

• Naturopath consultations
• Osteopath
• Podiatrist/chiropodist
• Speech therapist

If a referral is required, it must be current, and will be valid for one year after the date of issue.

If an x-ray is recommended by any of the above health practitioners, an additional $25 is covered towards this expense. No amount will be paid for any visit for which any amount is payable under the covered person’s Provincial Health Care Plan, unless permitted by law.

Charges, up to the provincial benefit maximum for semi-private rate, are eligible. A hospital is a place that:

• chiefly provides inpatient medical care for the injured, sick or chronically ill;
• has a staff of licensed doctors (M.D.) and 24-hour nursing care by registered nurses (R.N.); and,
• is approved as a hospital for payment of the ward rate under the provincial health plan.

Charges are covered at 100% of reasonable and customary charges for the rental or purchase of medical equipment based on the nature and severity of the covered person’s medical needs, when recommended by a licensed medical doctor (M.D.). Before incurring any major expenses, it is recommended you submit details to The PBAS Group to determine to what extent benefits are payable.

Covered items include, but are not limited to:

• Wheelchairs (purchase, $1,000 per lifetime; repairs, $250 per lifetime);
• Respiratory Equipment including oxygen, CPAP/BPAP machines and supplies ($1,500 per lifetime);
• Contact lenses/glasses following cataract surgery (one pair per lifetime);
• Canes, crutches, walkers, casts, splints, catheters, and colostomy supplies;
• Compression stockings or garments (excluding athletic or general-use apparel) (two items or pairs per benefit year);
• Insulin pump and diabetic supplies not covered under the prescription drug benefit (infusions sets, cartridges, and continuous glucose monitors) ($1,500 per benefit year);
• Intra-uterine devices (IUD’s) with no medicinal content, (one per benefit year);
• Aero chamber (one per benefit year);
• Custom-made rigid or semi-rigid braces (not for athletic use) for back, neck, arm or leg ($1,000 per lifetime, per condition);
• Non-dental prosthesis such as artificial limbs and eyes, including replacement if required because of a change in physical condition ($1,000 per lifetime, per condition);
• Wigs for a diagnosed medical condition or medical treatment resulting in full or partial hair loss ($1,000 per lifetime).

To qualify for reimbursement, medical equipment must be obtained through a licensed medical equipment supplier or a recognized, reputable retailer specializing in medical or healthcare products. Items purchased through third-party online marketplaces or non-verified vendors are not eligible.

Excluded items include those intended for athletic use; personal comfort or convenience items; fitness or wellness equipment; safety or environmental modifications; cosmetic, self-care or hygiene items; self-help or environmental control items; over-the-counter or non-prescription items; experimental or non-approved devices; duplicates or upgrades. Items with both medical and non-medical uses are not covered, such as, but not limited to: heating pads or light therapy devices, communication aids, air conditioners or cleaners, and whirlpool baths or saunas. Not all exclusions are listed. Medical supplies not listed in this booklet are subject to prior approval from the administrator.

In order to submit a claim for medical equipment, a letter (referral) will be required from a licensed medical doctor (M.D.) describing the nature of the disability, the type of equipment, medical need and estimated duration required.

Charges for home nursing care by a registered nurse (R.N.) or a Victorian Order Nurse (V.O.N.) who is not a member of your family, and does not normally live in your home, are covered at 100%, up to $25,000 every three benefit years, when ordered by a licensed doctor (M.D.) as medically necessary for disability that requires the specialized training of an R.N. or V.O.N.

Charges for custom-made orthopedic shoes (including repairs), arch supports, molds and orthotics, which have been specially designed and molded for the covered person, are covered at 50%, up to $250 per benefit year, when required to correct a diagnosed physical impairment and when recommended by a licensed medical doctor (M.D.) or Podiatrist/ Chiropodist.

Coverage does not include footwear that are primarily designed for non-therapeutic purposes, including athletic, recreational, or performance enhancement use, or for general comfort.

The plan covers a list of Health Canada approved prescription drugs, professionally compiled to address the needs of students at 80%, up to $3,000 per benefit year. This Plan uses “The Student Managed Drug Formulary” to help reduce the cost of the plan while maintaining comprehensive quality care and benefits. Access to the drug formulary can be found below.

By visiting Pharmasave on campus, Walmart, or Costco, and showing your benefit card, you can receive coverage of up to 100% on your out-of-pocket prescription drug costs (up to a max of $40).

Eligible drugs include those approved by Health Canada, and are within the following general categories:

• Eligible drugs which by law require a prescription for purchase; and,
• Compound mixtures where one of the ingredients is an eligible item.

Coverage is limited to the cost of the lowest priced equivalent item in the applicable generic category that can be legally used to fill your prescription. The plan covers up to a 34-day supply of therapeutic (acute) drugs, and up to a 100-day supply for maintenance drugs, unless prior approval is obtained from The PBAS Group.

It should be noted that drugs are only considered eligible if they were prescribed by a licensed medical doctor (M.D.), licensed dentist or another professional authorized by provincial legislation to prescribe drugs, and dispensed by a registered pharmacist or licensed medical doctor (M.D.).

The plan is limited to one intra-uterine device (IUD) per benefit year. IUD’s that do not contain medicinal content may be eligible for coverage under the Medical Equipment benefit.

The only drugs not legally requiring a prescription that will be reimbursed if accompanied by an official prescription receipt from the pharmacist, are:

• HPV and pneumococcal vaccines;
• Vaccines/serums (if required for course of study, school authorization required);
• Diabetic supplies such as insulin, syringes, needles, diagnostic reagents for the diagnosis and monitoring of diabetes, lancets, sensors and readers. Diabetic supplies not listed may be eligible for coverage under the Medical Equipment benefit;
• Smoking cessation products are covered at 80% up to $500 per benefit year.

Additionally, the Plan covers the following, without a prescription, up to the benefit maximum:

• Digital contraception apps (such as Natural Cycles);
• Rapid at-home STI testing kits (such as trusti).

Information about these providers can be found in the Plan Member Portal under Preferred Providers. A detailed invoice is required.

Specifically excluded from coverage, whether legally requiring a prescription or not, are:

• Allergy testing and all forms of allergen immunotherapy, including but not limited to allergy serums, extracts, injections, and sublingual tablets or drops;
• Cannabis and psychedelics;
• Dietary foods and supplements;
• Fertility drugs;
• Hair loss and hair growth agents;
• Household products such as, but not limited to, soap and toothpaste, prescription mouthwash;
• Oral drugs for the treatment of erectile dysfunction;
• Anti-obesity drugs;
• Vitamins (other than injectable);
• Vaccinations, unless listed or required for course of study.

This benefit is underwritten by Chubb Life Insurance Company of Canada under Policy Number SG102526

This benefit applies to the insured student only. If you become disabled while covered, and are confined at home or in a hospital for a minimum of 15 consecutive school days, you are eligible for the private tutorial services by a qualified teacher, $15 per hour, up to $1,000 per disability. The teacher must be approved in advance by the Students’ General Association. Disabilities due to the same or related cause will be treated as one disability.

If the disability is the result of an accident, confinement must occur no later than 100 days after the accident. Disabled means that you cannot, because of illness or injury, engage in most of the standard activities a person of the same age or demographic.

Charges for the following vision care are covered to the combined maximum of $150 every 24 months:

Eye examinations, by an Ophthalmologist or Optometrist, registered and legally practicing within the scope of their license, are covered. No amounts will be paid for contact lens fitting fees or retinal photos.
Lenses and frames or contact lenses are covered, when prescribed by an Ophthalmologist or Optometrist. Itemized invoices are required.
Laser eye surgery in lieu of lenses and frames will also be covered, up to the benefit maximum.

No amount will be paid for electronic components for smart glasses, or non-prescription glasses, such as safety or sunglasses. When purchasing glasses or contact lenses online, you are required to submit a copy of your current prescription with your claim.

No amount will be paid for care, services or supplies:

• if the payment is prohibited by law;
• if the benefit is covered under any government plan or law;
• where no charge would have occurred in the absence of this coverage;
• for care, supplies, or treatment which is not medically required;
• for dental work, excluding Accidental Dental;
• for testing including, but not limited to, allergies, sleep studies, learning disabilities;
• for care or treatment that exceeds the normal care or treatment that is recognized as customary and common practice for an illness or injury, in accordance with current therapeutic practice; or,
• medical supplies, services, or treatments not listed in this booklet, unless with pre-approval from the Administrator.

No amount will be paid for any charge incurred as a result of:

• war, whether declared or not;
• insurrection, rebellion or participation in a riot or civil commotion;
• purposely self-inflicted injury; or,
• the covered person’s commission of, or attempt to commit, an assault or a criminal offence.

Eligible dental expenses are covered when they are incurred while the person is insured and service is provided by a licensed dentist, dental hygienist, anesthetist, or specialist. The term “dentist” in this provision intends to include all of the above. If treatment is given by a specialist, the amount paid will be limited to the amount stated for that treatment in the Ontario Dental Association Suggested Fee Guide for General Practitioners in effect at the time of treatment, as described below. Treatment by a specialist will only be covered if a comparable dental code exists in the General Practitioner Fee guide of the province of the Plan.

There is an overall dental maximum of $750 per benefit year, however certain items are specifically excluded and limits exist. Unused benefits from a specified time frame cannot be utilized in a future period. It is recommended to submit a predetermination to ensure you are covered for your procedure.

The Plan provides coverage for eligible diagnostic and preventative services at 70%, included in the overall maximum.

Examinations

• Initial or complete examinations (once every 36 months)
• Recall examinations (once every nine months)
• Specific examinations
• Emergency examinations

X-rays

• Full mouth series x-rays (once every 36 months)
• Periapical x-rays (up to 16 films every 36 months)
• Bitewing x-rays (up to four films per student year)
• Panoramic x-rays (once every 36 months)

Cavity Prevention

• Polishing or cleaning teeth (once every nine months)
• Recall scaling (four units per benefit year, combined with root planing)
• Fluoride treatment (once every nine months)
• Pit and fissure sealants (once per tooth every three years for dependants age 16 or younger)
• Space Maintainers (once per space for primary teeth, dependants age 14 or younger)

The Plan provides coverage for eligible restorative services at 70%, included in the overall maximum.

Fillings

• Sedative, silver or white fillings
• Retentive Pins

The Plan provides coverage for eligible endodontic services at 70%, included in the overall maximum.

• Pulpotomy
• Root Canal (once per tooth)

The Plan provides coverage for eligible periodontic services at 70%, included in the overall maximum.

• Oral Disease
• Desensitization
• Gingival Curettage
• Gingivectomy
• Flap Surgery
• Tissue Graft
• Root Planing (four units per benefit year, combined with scaling)

The Plan provides coverage for eligible oral surgery services at 70%, included in the overall maximum.

Minor

• Extractions, erupted teeth
• Residual root removal

Major

• Extractions surgical
• Alveoloplasty, gingivoplasty, stomatoplasty, vestibuloplasty
• Surgical excision
• Surgical incision
• Fractures
• Frenectomy
• Post surgical care

The Plan provides coverage for eligible anesthetic services at 70%, included in the overall maximum.

• Local anesthesia
• Deep sedation
• Inhalation technique
• Intravenous sedation

No amount will be reimbursed for the following expenses:

• bite plates, bridges, major restorative (unless listed), bleaching, orthodontic services;
• any anesthesia administered in a hospital;
• dental charges that could be claimed under Workers’ Compensation;
• dental charges not included in the current provincial fee guide for General Practitioners;
• cosmetic procedures, experimental treatment or testing;
• charges for appointments that are not kept;
• charges for the completion of claim forms;
• treatment to correct temporomandibular joint dysfunction of the jaw;
• endodontic treatment that started before the effective date of coverage;
• dental appliances (unless listed);
• any orthognathic surgery (remodeling or reconstruction of your jaw);
• procedures or supplies used in vertical dimension corrections (changing the height of the teeth) or to correct attrition problems (worn down teeth); or,
• implanting fabricated teeth or any major surgery resulting from implanting fabricated teeth.

This benefit is provided by Orion, under group policy number SBA10001.

As part of the health plan, you and your eligible dependants are covered for hospital services, physicians, and other services for emergency treatment of an injury or illness while traveling outside of the province of Ontario, including international travel. The travel plan covers reasonable and customary charges, which are in excess of the provincial health-care allowance.

You’re covered for up to 90 days per trip, for an unlimited number of trips taken during the time you’re covered. The maximum coverage is $5,000,000 per trip.

When travel is required to complete a course of study, coverage can be extended to 365 days, following confirmation from your academic supervisor. Please contact the Students’ Association or The PBAS Group to obtain a 365-day Medical Assistance Travel Card. For complete details of coverage and/or to print your 90- day Medical Assistance Travel Card, visit macgsa.drawbridge.ca.

From Canada and the US, call toll free: 1-888-997-0152
From anywhere else in the world, call collect: +1-519-251-0152

If calling is not possible, contact us via Chat:
SMS: 1-450-234-8044
WhatsApp: 1-888-657-7611
Webchat: orion.xodus.ca/assistance
Email: orionassistance@xodus.ca

If you have an emergency while traveling, you must contact Orion immediately before seeking medical treatment. If you are unable to contact Orion due to the nature of your emergency, you must have someone else call on your behalf, or you must call as soon as medically possible. Orion is available to take your call 24 hours a day, 7 days a week.
In a life threatening emergency situation, call 911 or the local emergency number.

The Maple Assistance Program gives you access to mental health and wellness support directly through your Maple account. When you are dealing with stress, anxiety, relationship issues, financial concerns, legal questions, or just need someone to talk through what is going on, you can connect with trained counsellors, well-being coaches, legal consultants, and financial experts through phone, video, or in-person appointments with a large national network of providers, with services available in both English and French.

Here's what's included

• Counselling — issue-based sessions with trained counsellors to address the challenges that matter most to you
• Legal consultations (LegalConnect) — phone-based legal information, plus an optional referral to a local lawyer that includes one free 30-minute consultation and a 25% discount on standard fees where applicable
• Financial guidance (FinancialConnect) — telephonic support covering personal finance questions and planning topics
• Work-life resources (FamilySource) — digital resource lists for childcare, elder care, pet services, relocation, housing, and everyday life needs
• Digital self-care tools (CCBT) — interactive cognitive behavioural therapy programs for depression, anxiety, stress, chronic pain, sleep, and overall wellbeing
• Well-being coaching — sessions focused on nutrition, sleep, weight management, stress management, burnout, and resilience
• Crisis support — 24/7 crisis assessment and triage when you need immediate help