| Frequently Asked Questions |
- May I opt-out of the plans?
- When does coverage start and end?
- Can I buy coverage for my spouse and/or my children?
- Can I buy coverage for myself?
- How do I obtain prescription drugs?
- Does the Plan pay for the pharmacy's dispensing fee?
- What prescription drugs are covered?
- How much of the prescription drug cost is covered (co-payment)?
- What happens when I am vacationing, travelling or when I am serviced by a pharmacy that does not have computer access to Green Shield files?
- Are there any exclusions?
- Are glasses and contact lenses covered?
- What else is covered? (Paramedical/Extended Health Services)
- How do I get reimbursed for Paramedical/Extended Health Services?
- What about emergency out-of-province/out-of-country hospital, surgical, and medical expenses benefit?
- Are there any limitations for out-of-province/out-of-country coverage?
- How do I claim benefits when out-of-province/out-of-country?
- What about travelling outside Canada?
- How do I make a dental claim?
- How do I complete the Standard Dental Claim Form?
- The amount my dentist charged me is different from the "eligible amount" shown by the insurance company. Why?
- I am going home during the Christmas holidays. May I visit my regular dentist in my home town?
- Are orthodontics covered?
May I opt-out of the plans?
You may opt-out of the SGPS Health Plan and/or the SGPS Dental Plan only if you have an alternative and equivalent health/dental plan.Opt-outs will be processed on-line this year during the Opt-out Period!
You will be required to give your name, your student number, your email address, your insurance provider name(s) and policy number(s). A random sampling of about 1 in 5 students will be required to provide proof of coverage in the form of either:
Health/dental card from another provider showing your name, the insurance company name, and the policy number. If you wish to opt out of both the health and dental plans, then this card must also clearly indicate both kinds of coverage. Note: a prescription card is not always proof of coverage to opt-out of the dental plan;
OR
A letter from employer or parent's/spouse's employer stating that you are covered by the company's plan(s). This letter should state the insurance company, the policy number, and must explicitly say that you are covered for BOTH health and dental;
OR
A recent paid claim receipt clearly indicating you as the claim recipient and showing both health and dental coverage.
No opt-outs are accepted after the final deadline. If you are unable to opt-out on-line during the opt-out period, contact the office (in person, by phone or email) BEFORE THE DEADLINE in order to apply for alternate arrangements.
When does coverage start and end?
Coverage is valid 24 hours a day, seven days a week, from September 1 to August 31.
If you enroll in the Plan(s) in the Winter term, your coverage is from January 1 to August 31.
All claims from the 2006/2007 year must be submitted before October 1, 2007, and must have been incurred no later than August 31, 2007.
Black Out Period
Please note that due to the time it takes for Green Shield to upload eligible students
onto their system following the opt-out period, any claims received by Green Shield
before mid-October will be rejected. Please do not send claims to Green Shield
before mid-October. If you require a prescription between September 1 and
mid-October, you will have to pay for the prescription upfront and then mail a paper
claim to Green Shield after mid-October. If this delay causes you financial
hardship, please contact the SGPS office.
Can I buy coverage for my spouse and/or my children?
Yes. We have added Couple Coverage to the Plans this year! Couple Coverage is available for your spouse only or one dependent only during the opt-in period that corresponds with the term you registered (September or January). Couple coverage is available for an additional cost of $165.44 (health only), $169.06 (dental only), or $334.51 (health and dental). Costs are prorated for January enrolment.
Family coverage is also available if you have a spouse and/or more than one dependent. You must opt in during the opt-in period that corresponds with the term you registered (September or January) only. Family coverage is available for an additional cost of $221.23 (health only), $258.17 (dental only), or $479.40 (health and dental). Costs are prorated for January enrolment.
Can I buy coverage for myself?
Yes. Any SGPS member not automatically assessed is eligible to opt-in to the SGPS Health and Dental Plan by contacting the SGPS office directly in September 2006 or January 2007 only. (You may enroll in the Plan(s) ONLY during the first month of the term in which you first register).
All eligible students must pay the SGPS student activity fee of $55.75 in order to opt-in to
the SGPS health/dental plan.
How do I obtain prescription drugs?
Your student card serves as your health plan card. Simply present your student card when buying your prescription. The pharmacist will need the number on the sticker on the back of your card ("SGP" + student number-00) to access the Green Shield files to ensure eligibility.
If you have purchased couple or family coverage, your spouse/dependents numbers will be the same as yours except the numbers after the dash will be different. Typically, your spouses number would be (SGP + your student number-01), your first dependents number would be (SGP + your student number-02), your second dependents number would be (SGP + your student number-03), etc. When you purchase couple or family coverage at the SGPS office, we will provide you with Green Shield Student Drug/Dental Insurance family card(s) with these numbers so that your spouse/dependents will have them to carry with them.
Please note that you can only purchase a maximum of three months worth of your prescription at a time.
Does the Plan pay for the pharmacy's dispensing fee?
The Plan covers 80% of the pharmacys dispensing fee, to a maximum of $5.00 per prescription. Dispensing fees can range from anywhere from about $4 to about $11, so you may want to consider the dispensing fee cost when choosing a pharmacy. A list of some local pharmacies and their dispensing fees can be found here.Tip: If you are prescribed a "maintenance medication," you can save money by requesting a longer prescription. For example, if you request a three-month supply instead of three one-month supplies, what you pay towards the cost of the drug itself won't change, but you would pay only one dispensing fee instead of three, and so your cost over the $5.00 maximum would be paid only once.
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What prescription drugs are covered?
The Plan covers all prescription drugs which are prescribed by your physician, including oral contraceptives, anti-depressants, insulin supplies, and injectables, including allergy serums, insulin, and extemporaneous compounds provided that the mixture does not contain excluded items only. In addition, coverage is provided for drugs, medicines and supplies of a non-prescription nature that are required as a result of life-sustaining treatment for colostomy, cystic fibrosis, diabetes, Parkinsons Disease and heart disease. Some vaccinations are covered.
If you are wondering if your specific drug is covered call Green Shield at 1-888-711-1119 and have the drug DIN number ready.
How much of the prescription drug cost is covered?
The Plan pays 80% of the cost of the medication and up to $5.00 of
the dispensing fee (see note above regarding the dispensing fee) for prescription drugs, with a $5000.00 annual maximum for prescription drugs. You must pay the other 20% at the time of purchase.
What happens when I am vacationing, travelling or when I am serviced by a pharmacy that does not have computer access to Green Shield files?
Pay for the prescription. Request a receipt, and ask the pharmacist to indicate on the receipt the name, strength and quantity of medication dispensed. Forward the receipt
along with a yellow claim form to Green Shield's Drug Dept. address shown on the form. This claim form is also available at the SGPS office. A repayment cheque will be mailed to you.
Are there any exclusions?
Any drug or product that has not been prescribed by an authorized medical practitioner; vitamin products; patent medicines, some vaccines; blood and blood plasma; contraceptive devices (except oral); foam or gels, antacids, treatment for male pattern baldness, erectile dysfunction, fertility, anti-obesity medications, shampoos, cosmetics, laxatives and medicines that may lawfully be sold or offered for sale other than through retail pharmacies, and which are not normally considered by practitioners as medicines for which a prescription is necessary or required. Please contact Green Shield for a complete list of excluded medications.
Are glasses and contact lenses covered?
Yes, we have added vision coverage for 2006-2007! Your Vision Benefit carries a maximum of $100.00 over 24 months for prescription lenses (including contacts). This benefit does not include the cost of frames, prescription sunglasses, or safety lenses. In addition it does not cover the cost of broken or lost eyeglasses or lenses.
The Vision Benefit also carries an additional benefit of a maximum of $50.00 every 24 months towards the cost of an examination by a licensed optometrist. As a Green Shield subscriber, you have access to Green Shields national preferred provider vision network arrangement with The Bay Optical and Zellers Vision Centre stores. All Green Shield subscribers are eligible to receive a discount of 33% off the regular prices available at The Bay Optical and Zellers Vision Centers. This offer applies to all extra coatings and upgrades. (Excludes disposable contact lenses).What else is covered? (Paramedical/Extended Health Services)
Chiropractor, Massage Therapist (a doctor's referral is required), Physiotherapist, Registered Naturopath, Speech Therapist (a doctor's referral is required), Chinese Medical Practitioner, Acupuncturist, and Registered Dietitian are all covered at $20.00 per visit up to a combined maximum of $300.00 per benefit year (not $300.00 per paramedical service category).
Custom made orthopaedic shoes (not requiring a brace) and custom made orthotics are covered at 80% up to $250.00 every two benefit years. A doctors referral is required.
80% ambulance cost for local land travel.
How do I get reimbursed for Paramedical/Extended Health Services?
You will have to arrange for full payment with the provider. Remember to
obtain a receipt. Download and complete a yellow claim form This claim form is also available at the SGPS office. For your records, be sure to make copies of the receipt and the claim form before sending the originals to Green Shield at the appropriate address listed on the claim form. A repayment cheque will be mailed to you.
What about the emergency out-of-province/out-of-country hospital, surgical, and medical expenses benefit?
This benefit is provided by ETFS, Canada's largest provider of out-of-province coverage. Your ETFS policy number is 2855L002. This benefit will provide reimbursement to a $5,000,000.00 maximum for emergency out-of-province hospital, surgical, and medical expenses as follows:
- Hospital services in a public general hospital outside of the province of residence of the patient when the fees for such services are in excess of the amounts allowed by the Provincial Government Health Plan in the province of which the patient is a resident.
- Medical - surgical expenses for services of a legally qualified physician or surgeon rendered outside of the province of residence of the patient when the fees for such services are in excess of the amounts allowed by the Provincial Government Health Plan in the province of which the patient is a resident.
- For more information, download ETFS brochure here
Are there any limitations for out-of-province/out-of-country coverage?
In order to be covered under this policy, you must be covered under a provincial medicare plan or UHIP (basic medical).
The hospital, surgical, or medical services must be incurred as a result of accidental injury or emergency by the patient's attending physician while this coverage is in force.
The particular hospital service must be provided as a benefit under the ward coverage of the Provincial Government Health Plan.
Excess hospital, surgical, or medical fees will only be allowed as eligible expenses to the extent that they are reasonable and customary in the area where the covered services are received.
Please contact the SGPS office or ETFS directly for more information on out-of-province coverage.
In event of an emergency requiring hospitalization, ETFS must be notified immediately (call 1-866-870-1898 or [collect]: (819) 566-1898). Quote your ETFS policy number (2855L002). Benefits may be reduced if contact is not made.
For more information, download ETFS brochure here
How do I claim benefits when out-of-province/out-of-country?
Payment by ETFS for an eligible out-of-province/out-of -country hospital, medical, or surgical expense is processed only after the Provincial Government Health Plan in the province in which the patient resides has made reimbursement towards the service for which an out-of-province/out-of-country benefit is being claimed.
For complete information and instructions on how to file a claim with ETFS, Download ETFS brochurehere.Some of the key items you will need to submit include:
- All original itemized bills from the medical provider(s) stating patient's name, diagnosis, all dates and type of treatments, and the name of the medical facility and/or physician;
- The original prescription drug receipts (not cash receipts) from the pharmacist, physician or hospital;
- Proof of departure date(s) and return date(s);
- Claims must be filed within 90 days from the date the eligible expense was incurred.
What about travelling outside Canada?
Your Out-of-Country/Out-of-Province Emergency Travel Medical Coverage is included with the health portion of the plan. This coverage is provided through ETFS Global Excel. Travel anywhere in the world without worrying about what to do in the case of a medical emergency. Your coverage includes World Wide Assistance Service for on-the-spot medical assistance, emergency payments, including up-front guarantees, medical evacuation, and many other services. International Assistance is available 24 hours a day.
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IN THE EVENT OF AN EMERGENCY OUT-OF-COUNTRY,
YOU MUST CALL GLOBAL EXCEL IMMEDIATELY: |
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| From Canada and the U.S., call toll-free | 1-866-870-1898 |
| From anywhere else, call collect | (819) 566-1898 |
Identification: SGP + YourStudent# + 00 |
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| ETFS policy # 2855L002 | |
How do I make a dental claim?
Your dentist will do one of two things:
- partially fill out a Standard Dental Claim Form and give it to you for you to complete and send to Green Shield; OR
- send your claim electronically directly to Green Shield from his/her office.
- If you submit a Standard Dental Claim Form to Green Shield, they will send you a cheque for the eligible amount. Your dentist should have a Standard Dental Claim Form, or you may get one from the SGPS office or from http://www.greenshield.ca.You will likely be required to pay your dentist for the full amount of services rendered at the time of your appointment.
- For electronic claims: Green Shield offers "real time" electronic dental claim processing, which means that some dentists can submit your claim to Green Shield and immediately have the claim adjudicated by EDI (Electronic Data Interchange). This means that you pay your dentist only the amount of the services rendered that are not covered under the SGPS dental plan (co-payment amount).
- Finally, your dentist may simply send your claim electronically to Green Shield. You will likely be required to pay your dentist for the full amount of services rendered at the time of your appointment. Green Shield will send you a cheque for the eligible amount.
How do I complete the Standard Dental Claim Form?
Your dentist must partially complete the form. Ensure your mailing address is correct (top left corner).
Complete "Part 2 - Employee/Plan member/Subscriber" of the form by filling in your:
- group policy number (23786);
- "employer" (Queen's SGPS);
- insuring agency (Green Shield Canada);
- your name;
- certificate number/identification number ("SGP" + your student number + "00");
- your date of birth.
Complete "part 3 - Patient information":
- If you, the subscriber, are the patient, fill in your name, identification number, and birth date. If your spouse or dependant is the patient, fill in his/her name and relationship to you, the subscriber. Your spouse's identification number is your identification number ("SGP" + student number) plus the suffix "01." Your dependant's (s') indentification number is your identification number ("SGP" + student number) plus the suffix "02," "03," "04," and so on, depending upon how many of your dependants are covered under the plan.
- Indicate if dental claims will be made with another plan by answering question 2.
- Your dentist should complete questions 3, 4, 5.
Sign the bottom of the form (part 3) and indicate the date. Also sign the form near the top right-hand side ("I understand that the fees listed...), above the "office verification" line.
The amount my dentist charged me is different from the "eligible amount" shown by the insurance company. Why?
All dental procedures are coded by a five-digit number. The Ontario Dental Association compiles a fee guide every year that indicates how much each dental procedure is worth. This fee guide is used by the insurance industry to adjudicate dental claims. If your dentist charges more than the eligible amount for certain procedures, then he/she is exceeding the published amount agreed upon by the Ontario Dental Association.
I am going home during the Christmas holidays. May I visit my regular dentist in my home town?
Yes. The SGPS dental plan is "open," which means you may visit any dentist of your choice, even outside of Ontario. The claim procedure is the same as that if your dentist is in Kingston.
Are orthodontics covered?
No. The SGPS health plan does not include orthodontic coverage.