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					A member of the Sun Life Financial group of companies                        www.studentcare.net
Sun Life Assurance Company of Canada -



of this card for a list of these customizations and other important restrictions.
Formulary, customized for University of Waterloo students. Please see the reverse side
The FEDS/GSA Health & Dental Plan is a generic plan based on a modified ODB
                                                                              To the Physician:

or he can review important information about the student custom drug formulary.
Please present this card to your physician when medications are prescribed so that she
                                                                                To the Student:


                                                                       Group Number: 83307
                                                               HEALTH & DENTAL PLAN
                                                               FEDS/GSA




FEDS/GSA HEALTH & DENTAL PLAN
Additions:                                            Deletions:
 Generic doxycycline 100 mg.                           Sustained release formulations where an
 Famciclovir, valacyclovir, generic acyclovir, Avirax  underlying generic is available (except
 Epipen, Anakit, Glucagon Emergency kit                Tegretol CR, Ritalin SR, Biaxin XL)
 Dalacin vaginal cream, Dalacin T solution             Over-the-counter drugs
 Differin gel                                          Ciprofloxacin, cefadroxil, cefazolin, cefprozil,
 Flonase, Nasonex, Nasocort AQ, Symbicort Turbuhaler cefuroxime
 Insulin, syringes, ultra fine needle pen
 Preventive vaccines                                   Axid, Losec, Pantoloc
 Rosuvastatin (Crestor), rabeprazole (Pariet)         Maximums:
 Gardasil                                              Fertility drugs ($2000/lifetime)
 Altace HCT                                            Zyban (smoking cessation drug) limited
 DDAVP Melt                                            to 90 day lifetime maximum upon
 Alvesco inhaler                                       approval by Health Services.
 Novomix
 Diovan
Note:
 Extemporaneous mixtures will be covered providing
 one of the ingredients is a covered benefit.

                                       Sun Life Assurance Company of Canada -
www.studentcare.net                       A member of the Sun Life Financial group of companies