D.A. Townley  -  Plan Administrators Iron Workers Union Local 97 International Association of Bridge, Structural, Ornamental and Reinforcing Iron Workers 
 

health
benefits

        
 
 
 
 
 
 
 
 
 
 
 
   
   
   
 
 
 
 
   
 
 
 
 
 
   
 

Extended Health Care

 


Eligibility

Eligible Members and their registered* dependents are entitled to the Extended Health Care benefit.

*Spouse of an Insured Person, and unmarried dependent children to age 21, unless the dependent child is attending a recognized school, college or university on a full-time basis, in which case the maximum age will be 25. A child is not a dependent if he/she is eligible for or entitled to benefits under this Plan as a Member.

 


What are Extended Health Care benefits?
Extended Health Care is an extension of your medical coverage and is designed to protect the Member and his/her dependents against many of the expenses incurred during a period of illness.

 


Is there an annual deductible?
There isn't a calendar year deductible. All eligible expenses will be reimbursed at 90%.

 


Covered Expenses:

  1. Services of a graduate nurse (Licensed vocational nurse where an R.N. is not available) when ordered by the Attending Physician in the management of an acutely ill patient. Private Duty Nursing coverage limited to $25,000 per injury or sickness.
  2. Treatment by a licensed Chiropractor, Podiatrist, Speech Therapist, Acupuncturist, Naturopath, Clinical Psychologist, Physiotherapist, Masseur, (operating within the scope of their license), will be reimbursed at 50% up to a maximum of $400.00 per person per calendar year for each category. Payment of X-ray examinations required up to $50.00 per calendar year.
  3. Prescription Drugs (Generic Substitution Always) - Pay Direct Drug Card Benefit - present your drug card, along with your prescription, to your pharmacist and your prescription drug claim will be adjudicated right at the pharmacy. Reimbursement of prescription drugs is based on the cost of the lowest priced generic equivalent drug. Using your drug card eliminates the need to send in your prescription receipt and wait for reimbursement. Your Plan provides coverage for prescription drugs and medicines (including oral contraceptives) which require, and can only be obtained, with the written prescription of a licensed physician or dentist if provincial law permits. Refills are not permitted to be dispensed earlier than what is deemed to be reasonable and customary. Vacation supplies of your medications, which are outside the regular days supply limits must be pre-authorized by the Plan and must be paid for in full by the Member and submitted to the Plan for reimbursement. Smoking cessation products will be covered up to a combined lifetime maximum of $500 per person. Dispensing fees over $8.50 per prescription are not covered by this Plan.  
    Drugs and medicines that can normally be purchased "over the counter" are excluded regardless of a prescription having been issued. Fertility drugs, vitamins, preventative drugs, dietary foods and supplements are also excluded.  
    There are a number of prescription drugs which are not eligible under BC's Fair Pharmacare drug formulary, but may be eligible under their Special Authority Program. You may be requested by the Plan to have your doctor apply for Special Authority for one or more of the drugs you have been prescribed. Should Fair Pharmacare approve the application for Special Authority, such drugs will be applied towards your annual Fair Pharmacare deductible.  
    PLEASE NOTE: It is mandatory for all Members, who are BC residents, to register for the provincial Fair PharmaCare program and provide proof of such registration to the Administrator in order to continue to receive benefits under the Plan. To register for Fair PharmaCare call 604-683-7151 from Vancouver and toll free 1-800-663-7100 from the rest of BC or visit the Government of BC Website and follow the links to the BC PharmaCare site: www.gov.bc.ca
  4. PRESCRIPTION DRUG PRIOR AUTHORIZATION PROGRAM

    There are a number of prescription drugs which require prior authorization before they will be deemed as eligible under the Plan. The complete Prior Authorization Listing of these drugs can be found online at:Prior Authorization Program

    If your doctor prescribes you a drug that is on the Prior Authorization listing, when you take your prescription to the pharmacy, your pharmacist will be advised that you must obtain prior authorization first. You will then need to download the applicable Prior Authorization (PA) form for that drug from:Prior Authorization Program and complete your section, have your doctor complete a section, and then send the completed form to where indicated. This will be reviewed and the outcome of the assessment will determine eligibility. The decision will be communicated directly with the patient. If deemed to be eligible, an exception will be added to that patient's Plan record so that the drug card will accept that drug going forward.

    It's recommended that you refer to the Prior Authorization Listing while you are with your doctor, so that if the drug he/she wishes to prescribe is on the Listing, the applicable Prior Authorization Form can be printed and completed before you leave your doctor's office.

    If the prescribed drug is one that must be coordinated with the Provincial Fair PharmaCare Plan under Special Authority, you will also be advised to ask that your doctor apply for Provincial Special Authority for that drug on your behalf. This will not impact your ability to fill your prescription if it's approved under the Prior Authorization Program, but in order to ensure continued eligibility, the decision from Fair PharmaCare must be received by D.A. Townley within 90 days of the request.
  5. Professional ambulance service.
  6. Initial artificial limbs or eyes required to replace natural limbs or eyes lost while insured. Crutches, splints, oxygen as well as rental of iron lung and durable equipment for therapeutic treatment.
  7. Dental treatment necessary to repair or alleviate damage to natural teeth resulting from an accident occurring while insured, provided the expense is incurred within two years from the date of such accident.
  8. Hearing Aids for non-occupational conditions only, when prescribed by the Attending Certified Ear, Nose and Throat Specialist. The maximum benefit during a five-year period shall not exceed $400.00 per person and does not include payment for repairs and maintenance, batteries or recharging devices, or other such accessories.
  9. Custom built Orthotics, prescribed by a medical doctor or podiatrist, are limited to two pair per calendar year to a maximum of $400.00.
  10. Custom built Orthopaedic Shoes limited to two pair per calendar year, when needed as a result of a disability incurred while insured for this benefit, to a maximum of $400.00 per pair.
  11. Hospital charges for the difference between ward cost and semi-private, or when medically necessary, private accommodations.
  12. "Routine" eye examinations that are not covered by the Medical Services Plan of BC will be reimbursed at 90% up to a maximum of $75.00 every 24 months.
  13. Co-insurance charges of up to $8.50 per day for those private hospitals approved by the Ministry of Health to a maximum of 30 days confinement for any one period of illness.
  14. The vaccine for Shingles.
  15. Coverage for prescribed treatment to cure Hepatitis C will be limited to one cure per lifetime.

 


Out-of-Province Benefits

  1. Physicians Services: Reasonable and customary charges for Physician’s services required in the event of an emergency while traveling or on vacation outside the Province of British Columbia, over and above the amounts paid or payable by the Medical Services Plan of British Columbia.
  2. Hospital Charges: In the event of an emergency while traveling or on vacation, the total amount of the hospital room charge over and above that covered by B.C. Hospital Programs. The maximum period payable for any one accident or sickness shall be 60 days. This does not include private or semi-private room.
  3. In an emergency, services and/or supplies as become necessary outside the Province of British Columbia on the same basis as they would be entitled to coverage in the Province of British Columbia.
For more information, please see the Out of Province/Canada Travel Medical Emergency Insurance booklet.
 

 


How a Claim is Made
Obtain an Extended Health Care benefits claim form from the Administration Office or the Plan web site and follow instructions on the reverse side of the form. When properly completed, return to Administration Office.

 


Is there a lifetime maximum?
Yes, a total maximum amount of $1 million is available to each Member and $1 million for each eligible dependent during a lifetime. For Members age 80 onward, benefits will be limited to $20,000.00. Benefits in excess of the $20,000.00 provided by Local 97 Self Insured Extended Health Care Benefits program will be limited to those expenses incurred within 52 weeks of the date of covered injury or sickness.

 


Exclusions and Limitations
This Plan does not cover incurred expenses for, contributed to, or caused by:

  1. the failure of any person to make claim for and receive benefits within the time and in the manner prescribed under or pursuant to the Basic Medical Plan to which you are entitled.
  2. the expense of a Physician and/or Surgeon except as described under “Out-of-Province Benefits” for emergency treatment while traveling outside British Columbia and is limited thereby.
  3. war or act of war or participation in a riot or civil insurrection.
  4. suicide or any attempt thereat.
  5. orthoptic treatment and refractions.
  6. Dental services except as set out in (6) of “Covered Expenses.”
  7. any portion of a Specialist’s fee not allowable under the Basic Medical Plan due to non-referral, or any amount of fees charged by any practitioner in excess of the recognized fees for such service.
  8. services which are eligible for payment by the Medical Services Plan of British Columbia, Workers’ Compensation Board or any tax supported agency, without cost or at nominal cost by public authorities.
  9. services and supplies for cosmetic reasons.
  10. expenses incurred outside the Province, on an elective basis. Service will only be allowable for an unexpected illness or injury while the Insured Person is temporarily visiting outside the Province.
  11. eligible expenses must be submitted to the Administration Office during the calendar year following the year in which expenses were incurred.


Form Links
Extended Health Benefits Claim Form
 

related Links
Filing an Extended Health Benefits Claim
Printable Version of the Health & Welfare Plan Booklet
Printable Version of the Out of Province/Canada Travel Medical Emergency Insurance Booklet

 
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