PGSS Handbook 2006-07

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PGSS Handbook 2006-07 Powered By Docstoc
Carrier: Sun Life
Plan name: PGSS Health & Dental Plan
Policy no.: 56961
Identification no. : (McGill ID#)
Plan holder: (Student's name)

WHO CAN BE COVERED?                                      PRICES FOR GRADUATE STUDENTS
                                  HEALTH      DENTAL       From September 2009 - August 2010
                                                                            Health Plan ............ $224.75
Graduate students                                                         Dental Plan ............ $189.75
Postdocs                                                                  BOTH ........................ $414.50
International graduate students                  
Spouses & children                              
                                                             From January 2010 - August 2010*
HOW DO I PAY FOR COVERAGE?                                                  Health Plan ............ $149.83
                                                                            Dental Plan ............ $126.50
Registered by September 30, 2009 McGILL        PGSS                         BOTH ........................ $276.33
Full-time status                  
Additional session status                               PRICES FOR SPOUSE OR ONE CHILD
Non-thesis extension status                                           in addition to the students' price
Postdocs                                                  From September 2009- August 2010
All other statuses                                                         Health Plan ............ $224.75
Spouses & children                                                         Dental Plan ............ $189.75
Registered after Sept. 30, 2009*                                           BOTH ........................ $414.50
Registered for Winter term only*                 
McGill will charge you automatically for these fees          From January 2010 - August 2010*
through your tuition and student fees account.                              Health Plan ............ $149.83
PGSS will manually enrol you through payment and                            Dental Plan ............ $126.50
submission of documents at the PGSS office.                                 BOTH ........................ $276.33
* This can only occur during adjustment periods & must
be requested to PGSS during the adjustment periods.                        PRICES FOR FAMILIES
                                                                      in addition to the students' price
HOW DO I CONFIRM MY COVERAGE?                                 spouse + unlimited number of children

A software system charges fees based on McGill's           From September 2009 - August 2010
fee codes. Please verify your charges and coverage                          Health Plan ............ $449.50
through Minerva, or by calling the PGSS office.                             Dental Plan ............ $379.50
                                                                            BOTH ........................ $829.00
Available in the PGSS handbook, on the PGSS website,         From January 2010 - August 2010*
the ASEQ website ( and on various                             Health Plan ............ $299.66
pamphlets available at Thomson House                                        Dental Plan ............ $253.00
                                                                            BOTH ........................ $552.66
October 2, 2009 (fall term)                              * this category of coverage is available only
February 5, 2010 (winter term)                           to graduate students registered for the first
                                                         time in the Winter term or after Sept. 30, 2009.

                                CONTACT US FOR ASSISTANCE
                       ASEQ                                             PGSS
  1134 Ste-Catherine West                                               David Thomson House
                    Suite 700                                           3650 McTavish
          Montréal, Québec                                              Montréal, Québec
                     H3B 1H4                                            H3A 1Y2
         Tel: (514) 789-8776                                            Tel: (514) 398-3756
  Toll free: 1-866-795-4436                                             Fax: (514) 398-1862
                                                   Carrier: Sun Life
                                                   Plan name: PGSS Health & Dental Plan
                                                   Policy no.: 56961
                                                   Identification no. : (McGill ID#)
                                                   Plan holder: (Student's name)

This information is intended as a basic explanation of the benefits available to you through the
PGSS Health & Dental Plan. The material summarizes the important features of your group
plan and is prepared as information only and does not, in itself, constitute a contract. Benefits
are subject to all conditions, limitations, exclusions and other terms of the master group insurance
policy (available at ASEQ).
Groups numbers:
56961-2A (members with Québec Medicare) or 56961-2B (all other members)
Policy year:
September 1, 2009 to August 31, 2010

Eligibility and payment
Full-time & additional session Canadian Masters & Ph.D. students, and postdocs
     - Compulsory Health Plan and Dental Plan fees charged through your student account
Full-time & additional session international graduate students
      - Compulsory Dental Plan fee charged through your student account
Members residing outside of Canada
      - Not eligible - withdrawal required during the Adjustment Period
Part-time Canadian graduate students
     - Optional enrolment payable at the PGSS Offfice during Adjustment Periods
Part-time international graduate students
      - Optional enrolment in the Dental Plan, payable at the PGSS Office during Adjustment Periods
Any students registered for their studies after September 30, 2009
      - Optional enrolment payable at the PGSS Office during Adjustment Periods

Spouse & Family Enrolments
The Plan gives you the option of enrolling your family (spouse and/or dependants) by
completing an Enrolment Form and paying an additional fee. Common law, civil union and same
sex couples are eligible. Enrolment Forms are available at

Blackout Period: (for New Students Only): The first two months of the Fall term while
ASEQ waits for complete enrolment lists. During this time, you may submit claims, but
reimbursement will only be mailed once the Blackout Period ends. Practitioners and pharmacists
do not accept Pay Direct or assignment of benefits during this period. Returning eligible
students who were covered in the Winter 2009 semester will not experience a Blackout Period
during the Fall semester. Similarly, only new Winter semester students will experience a Blackout
Period in the Winter 2010 semester.
Adjustment Period: The period at the beginning of each semester when you can either
withdraw or enrol yourself, your spouse and/or dependants in the Plan (if eligible).
Dependent children: Your children and your spouse’s children (other than foster children)
are eligible dependants if they are not married or in any other formal union recognized by law,
and are under age 22. A child who is a full time student attending an educational institution
recognized under the Income Tax Act (Canada) is also considered an eligible dependant
until the age of 26 as long as the child is entirely dependent on you for financial support.
Québec resident: For the purposes of the PGSS Plan, a Québec resident is someone who
holds a valid Québec Medicare card.
 Pay Direct Card: A card allowing non-Québec residents to fill prescriptions at most Canadian
 pharmacies without paying the full amount up front. The card is available online at and at the PGSS office.
Spouse: The person who is your spouse by marriage or under any other formal union
recognized by law, or your partner of the opposite sex or of the same sex who has been
publicly represented as your spouse for at least the last year.
                                                Carrier: Sun Life
                                                Plan name: PGSS Health & Dental Plan
                                                Policy no.: 56961
                                                Identification no. : (McGill ID#)
                                                Plan holder: (Student's name)

The Plan covers most medications legally requiring a prescription, either the generic
equivalent or the lowest actual cost. Most oral contraceptives, anti-smoking aids and
insulin are covered under this benefit. Certain brand name drugs are covered only if
your doctor indicates "no substitution" on the prescription. Benefits are not payable for
over-the-counter drugs, fertility drugs, male pattern baldness remedies, vitamins (unless
injected), vitamin and mineral preparations, food supplements, Viagra, or drugs not
approved for sale in Canada. Please contact ASEQ for further information relating to
prescription drugs.
Under the Québec Public Prescription Drug Insurance Plan (RAMQ), all Québec residents
must be covered under a private (not student) drug plan directly or as a dependant.
Residents who do not have access to a spousal/parent or employee insurance plan must
register with the RAMQ Drug Plan. All claims for prescription drugs must first be submitted
to this other plan or to the RAMQ before being submitted to the PGSS Health Plan.
Québec residents can be covered for up to 100% of eligible prescription drugs by
combining their private/RAMQ and PGSS Health Plan. For registration and information,
call the RAMQ at 1 888 435-7999. After submitting your eligible prescription drug costs
to your private/RAMQ Drug Plan, you can use your PGSS Health Plan to cover the
remaining costs, such as the co-payment or deductible from the other plan. Québec
residents are not eligible to use the Pay Direct card. This card is only for non-Québec
You should be covered under the Québec Public Prescription Drug Insurance Plan (RAMQ)
(see above)

1. Present your Medicare card at the pharmacy upon purchase.
2. Tell the pharmacist that you are registered with the RAMQ Drug Plan. Your prescription
   will be processed with your provincial coverage taken into account.
3. Pay any deductible or co-payment required to the pharmacist.
4. Attach your receipts (originals only) to the Extended Health Claim Form. Make photocopies
   of all forms, receipts, and documents before sending by mail.
5. Mail to Sun Life, who will process the remaining reimbursements.
The PGSS Health Plan will cover your eligible prescription drug costs up to 90%, using
the Pay Direct card. There is a yearly deductible for prescription drugs of $35 ($70 per
family). You can download the Pay Direct card from or pick one up at the
PGSS office. The card allows you to fill prescriptions at most Canadian
pharmacies without paying the full amount up front. The pharmacist will be able to
process the claim immediately, so you won't have to submit a hard-copy claim. Ensure that
you present both your valid student ID and Pay Direct cards. Please note that the Pay
Direct Card can't be accepted during the Blackout Period.

As an international student, your Québec Medicare coverage may not always be
identical to the Medicare coverage of Québec residents. Please consult the special
publication entitled "About RAMQ" to ensure you understand the coverage offered to
you through Québec Medicare and how you are eligible to submit prescription drug claims
to the RAMQ and/or the PGSS Health Plan.
                                                Carrier: Sun Life
                                                Plan name: PGSS Health & Dental Plan
                                                Policy no.: 56961
                                                Identification no. : (McGill ID#)
                                                Plan holder: (Student's name)

These regulations apply to students and postdocs covered by the Quebec Medicare program.
The RAMQ plan applies differently depending on your status and revenue. Consult RAMQ
for details or 1-888-435-7999. There are exceptions for international
students and postdocs obtaining a Medicare card for the duration of their time at McGill.
Find the document “About RAMQ” on the PGSS website for full details on these exceptions.
Residents of Quebec must be covered for prescription drugs by an insurance plan. If these
residents have access to an employee insurance plan (EIP), they are obligated to use
it. If these residents do not have access to an employee insurance plan, they are obligated
to use the RAMQ plan.
EIP’s can be offered by your employer, your parents' employer or your spouse's employer.
By virtue of being a "student plan", the PGSS plan does not qualify as an EIP. Therefore,
you are obligated to use the RAMQ plan as your "primary" drug insurance and can use
the PGSS plan as your "secondary" drug insurance. This means that you must claim your
prescription drug costs to the RAMQ plan first (or EIP if available), and afterwards to the
PGSS plan.
Eligibility: You must be under 65 years old without governmental employment assistance.
Deductible: A monthly $14.30 fee must be paid by you upon purchasing prescription drugs.
Coinsurance: After the initial $14.30, the remaining cost to be paid is 31% of the cost.
The other 69% is paid by RAMQ.
Maximum: Once you have paid out the monthly maximum, RAMQ pays for 100% of the
remaining prescriptions during the month. The monthly maximum varies up to $77.21
depending on your yearly income.
RAMQ premium: The amount of the annual premium varies from $0 to $570 per adult,
depending on net family income. This amount is in effect from July 1, 2008 to June 30,
2009 and is subject to change. The premium is collected every year by the Ministère du
Revenu du Québec when income tax returns are filled.

1. RAMQ will generally not reimburse prescription drug and pharmaceutical services
obtained outside Quebec.
2. RAMQ cannot reimburse prescriptions drugs after three months have passed since
the purchase date.
RAMQ considers you a "resident" if you have a Quebec Medicare card. However, McGill
considers you a "resident" if you have provided the Registrar's Office with proof of residency
in Quebec, allowing them to charge you Quebec tuition rates, rather than Canadian rates.
Therefore, the classification provided to PGSS by McGill may not correspond to your
classification with RAMQ. Please contact the PGSS office to make any corrections to your
residency classification for the PGSS plan via 514-398-3756 or
                                                Carrier: Sun Life
                                                Plan name: PGSS Health & Dental Plan
                                                Policy no.: 56961
                                                Identification no. : (McGill ID#)
                                                Plan holder: (Student's name)

Vaccinations: Prescription and non-prescription vaccinations are covered 100%, up to
a $50 maximum per policy year.
Vision Care: The Plan covers the cost of new or replacement eyeglasses or contact lenses.
The maximum allowed is $200 every 24 months. One eye exam is covered per policy year
up to $30 maximum. Laser eye surgery is covered to a maximum of $150 per policy year.
The Vision Network: ASEQ also offers a Vision Network, which is a comprehensive list
of optometrists and opticians who provide vision care to students at a preferred rate.
Consult for a list of participating clinics.
Health Practitioners: The Plan covers the cost of physiotherapists, chiropractors, naturo-
paths, osteopaths, dieticians (with a referral from a medical doctor), licensed psychologists,
podiatrists/chiropodists, athletic therapists and speech therapists for a maximum of $20
per visit per category of practitioner for a total of $400 per policy year. All health
practitioners must be registered with the appropriate licensing board in the province or
country where the treatment is received.
X-rays: One x-ray per policy year is included in the overall maximum for each of the
following categories of practitioners: chiropractors, osteopaths, and podiatrist/
Chiropractic Care: Some Québec chiropractors offer preferred prices to students
covered by the PGSS Health Plan. For a list of Network members in your region, visit
Medical Equipment & Services: The Plan covers the cost of stipulated medical
equipment, including hearing aids, crutches, wheelchair rental, hospital-type bed and
permanent prosthesis. Rigid and semi-rigid braces (not for athletic use), orthotics and
orthopedic shoes are also covered. A home nurse is also covered when certified in writing
as medically necessary by the attending physician and upon approval from Sun Life.
Before incurring any medical equipment expense, you should contact ASEQ for the
eligibility and any applicable maximums of all equipment. A medical doctor's authorization
is required for all medical equipment claims.
Diagnostic Services: Lab tests and ultrasounds used to diagnose an illness are covered
only if your provincial health care doesn’t cover these services. They must be performed
in a commercial lab. Ultrasounds for pregnancy and the monitoring of an illness are not
covered by the PGSS Plan.
Hospitalization: The Plan covers the cost of an upgrade from a public ward to a semi-
private hospital room. A hospital cash benefit will provide $50 per day of hospitalization
to offset any incidental expenses, payable from the first day and up to a 30-day maximum.
Ambulance: The Plan covers the reasonable and customary charges for air or land
ambulance service to the nearest hospital when an emergency requires immediate
medical attention. The maximum is $250 per occurence.
Tutorial Benefit: The Plan covers the cost of private tutorial services by a qualified
teacher if an accident or illness causes disability and confinement to a home or hospital
for seven (7) consecutive days. The benefit will be paid from the first day of confinement,
up to a maximum of $10 per hour, to a maximum of $300 per accident or illness. This
benefit is payable to the insured student only, and not to spouses or dependants.
                                                  Carrier: Sun Life
                                                  Plan name: PGSS Health & Dental Plan
                                                  Policy no.: 56961
                                                  Identification no. : (McGill ID#)
                                                  Plan holder: (Student's name)

Accidental Death & Dismemberment (AD&D)
The Plan provides insurance for the loss of life or limb for paralysis caused by an accident.
It provides payment of sums up to $37,500. For more details on AD&D benefits, eligibility
and claim submission, contact ASEQ.
Dental Accident
The Plan covers the repair/replacement of natural teeth damaged through an accidental
blow to the mouth according to the Provincial Dental Fee Guide for General Practitioners
(the province where the service was performed). If you visit a specialist for covered services,
your reimbursement will be processed according to the equivalent General Practitioner fee.
Treatment must be completed within 12 months following the accident. The maximum
paid is $2,500 per accident.
Travel Health Coverage
The Plan covers hospital, physician and other services for emergency treatment of an
injury or illness while travelling outside of the province in which you are residing
(including international travel). It covers reasonable and customary charges, which are
in excess of the provincial Medicare allowance. You are covered for up to 120 days per
trip, for an unlimited number of trips taken within the policy year. The maximum
coverage is $5,000,000 per incident. You are also covered up to $1,500 for trip cancellation
and up to $5,000 for trip interruption in case of a medical emergency for each trip taken
during the policy year.

Students who are away on a recognized academic exchange can have their travel health
benefits extended during the first 120 days of the trip and for the duration of their exchange,
plus another 120 days after their exchange, as long as they remain PGSS members, and keep
their provincial health-care coverage. You must notify ASEQ before leaving on an exchange.

The complete details of your benefits, coverage, and telephone numbers for emergency
assistance can be found in your Travel Health Passport, available at If you’re
planning to travel, you must bring this document with you. Health-care providers outside
Canada may require this information prior to providing services.

Please note that students and their dependants are not covered for out-of-province or
out-of-country emergency services once they reach age 80. If you, or your spouse, are
age 65 and older, a pre-existing condition clause applies to your medical conditions which
existed in the 365 days prior to your departure from your province or territory of
residence. For more details, contact ASEQ.
Travel Health Claims
Travel health coverage is provided by Mondial Assistance. If you use any of your travel
benefits, you must call Mondial Assistance immediately to find out how and when to
submit your claims. For more information visit and download the
Travel Health Passport.
Mondial Assistance
Toll-free (Canada & US):                  1 866-759-2882
Toll-free (International):                1 800 9220-9220
Collect calls:                            (519) 342-4948

Have your student ID number and contract number (no. 4709) on hand when you call.
                                                      Carrier: Sun Life
                                                      Plan name: PGSS Health & Dental Plan
                                                      Policy no.: 56961
                                                      Identification no. : (McGill ID#)
                                                      Plan holder: (Student's name)

The benefits of your PGSS Dental Plan are part of a special program for students. Your
dental benefits consist of two elements:

The insured portion of your PGSS Dental Plan covers a percentage of the recommended
fee for covered services, according to the Provincial Dental Fee Guide for General
Practitioners (according to the province where the service was performed), as indicated
in the chart below. If you visit a specialist for covered services, your reimbursement will
be processed according to the equivalent General Practitioner fee.

The ASEQ Dental Network is an exclusive service provided to students enrolled in the
PGSS Dental Plan. Network dentists, conveniently located in Montréal and other regions
of Québec and Canada, offer a reduction of 20-30% off the Provincial Dental Fee Guide
for General Practitioners' price of eligible dental services (refer to the chart below). You
are covered for the insured portion regardless of the dentist you choose. An updated list
of Network members is available at

                               INSURED PORTION (1)            NETWORK COVERAGE TOTAL

Preventive services                            65%                         30%                95%
(recall exams (2), cleanings (2),
extraction of impacted teeth (3))
Basic services                                 50%                         20%                70%
(fillings (4), oral surgery,
endodontics, periodontics)

Major restorative services                      50%                        20%                70%
(crowns, bridges, posts)

1. Percentage of Provincial Dental Fee Guide for General Practitioners (province in which the service
   was performed).
2. Recall exams, cleaning/polishing, bitewing x-ray, oral hygiene instruction and the application of
   fluoride are covered once every 6 months. Scaling is covered up to four units per policy year. A
   complete exam (often called a new patient exam) is only covered once per 36 months.
3. The extraction of impacted teeth is part of preventive services. The ASEQ Dental Network
   reduction, however, will be 20% as this is considered oral surgery.
4. Fillings in amalgam (metal) are covered for all teeth. Composite (white) fillings are covered for the
   front teeth and pre-molars only. If you choose to have your back teeth filled in composite, your
   claim will be reimbursed according to the amalgam fee.
* Services performed by an orthodontist are not covered by the Dental Plan.

The maximum paid by Sun Life per policy year (Sept. 1, 2009 - Aug. 31, 2010) on the
insured portion of the Dental Plan is $750. Certain exclusions and limits may apply.
Before receiving dental treatment for work that is expected to cost $300 or more, you
should submit a "predetermination form" obtained from your dentist for an estimate of
reimbursements to be assessed by Sun Life.
                                                  Carrier: Sun Life
                                                  Plan name: PGSS Health & Dental Plan
                                                  Policy no.: 56961
                                                  Identification no. : (McGill ID#)
                                                  Plan holder: (Student's name)

Claim forms are available at or, and at ASEQ
and PGSS . Photocopies of blank claim forms may be used . Only original receipts are accepted.

You can use your health and dental benefits anywhere in the world. Reimbursements
are made in Canadian funds and calculated at the exchange rate of the day the claim
is processed. Reimbursement is limited to what the service would have cost if done in
Canada. When applicable, claims will be coordinated with your provincial Medicare
coverage. Ensure that you submit detailed receipts for services performed while outside
of Canada.
Refer to the section on prescription drugs to find instructions on purchasing and making
prescription drug claims. Your provincial status will determine how you can buy and
obtain reimbursements for these expenses.
Québec residents who are claiming balances for prescription drugs should also follow these steps.
1. Complete and sign the health claim form (include your student ID # and group number);
2. Attach the original receipts and all other required documents (eg. doctor's referrals)
3. Make photocopies of all forms, receipts and documents before sending by mail.
4. Mail to the insurance company at the address indicated on the back of the claim form.
5. If using the Network: Present your student ID card to have the insured portion of the
   expense paid on a pay-direct basis. Complete and sign the claim form with the optometrist.
   S/he will be responsible for processing the remainder of the expense with the insurance
   company. Please note that Greiche & Scaff and LASIK MD do not offer the
   Pay-Direct system.

Contact ASEQ for instructions on how to submit these expenses for reimbursements.
1. You and your dentist must complete the dental claim form together.
2. Forms can be submitted by mail or electronically by the dentist's office.
3. If you are using the dentist's generic claim form, ensure that you indicate the Plan's
   group policy number and use your student ID for the 'certificate' or 'identification' number
4. You can assign benefits to your dentist by signing the box on the dental claim form
   giving authorization to assign benefits to the dentist. Reimbursement will be sent directly
   to the dentist. You will only have to pay the portion not covered by the insurance and/or
   Dental Network reduction. Consult your dentist to find out if s/he accepts this method.
Those with simultaneous coverage with other plans should contact ASEQ for instructions.
Health and Dental claims must be received by Sun Life no later than 90 days after the end
of the policy year in which claims were incurred or 90 days after the end of your coverage,
whichever is sooner. Accidental death and dismemberment claims must be submitted
immediately. Prescription drugs claims should be submitted immediately after purchase.
                                                Carrier: Sun Life
                                                Plan name: PGSS Health & Dental Plan
                                                Policy no.: 56961
                                                Identification no. : (McGill ID#)
                                                Plan holder: (Student's name)

A growing number of important health-care services are not covered by provincial
Medicare. For many students and postdocs, paying for these services can lead to financial
hardship, while others cannot afford them at all. To help pay for these health services, this
plan was put in place by PGSS. The Plan is uniquely designed for you, providing a
comprehensive package of health, dental, vision and travel benefits to fill the gaps left by
provincial Medicare, and other private plans.

Each year, in March, the PGSS holds a referendum to obtain the mandate from its members
to continue offering a compulsory insurance plan. The PGSS has offered such a plan to
McGill graduate students since 1995. The compulsory nature of the Plan is based on the
concept of 'group insurance' which offers better coverage at a better price for a larger
group rather than for individual users.
Dental costs, unforeseen accidents or illnesses, travel insurance costs, chronic illnesses,
sports injuries and birth control can be financial burdens for those who do not have
access to another insurance plan (coverage on parental plans generally ends at the age
of 25 and employer plans are not always available to full-time students). The PGSS Plan
provides its members with the security that if health expenses should arise, they will often
obtain some reimbursement for these costs.

Members contribute to the Plan by payment of the yearly price. The more members in
the group, the lower the price of the yearly cost.

The Plan functions as supplemental insurance which means it covers those costs that
are not covered by provincial Medicare. Whereas Medicare will cover the costs of visiting
an emergency room, it will not cover the cost of an ambulance. Nor will it cover the
costs of physiotherapy, contact lenses, or travel insurance. Supplemental insurance kicks
in to help you bear these outstanding costs.

Residents of Quebec, and those covered by Quebec Medicare, need to be aware of the
restrictions of group insurance relating to the prescription drug insurance with PGSS.
Please refer to the information “About RAMQ" on the next page.

Eligibility for enrolment and withdrawal are outlined on p. 1 of this booklet. Please refer
to these details prior to making decisions on your coverage for you and your family.

Enrolments and withdrawals occur during the adjustment periods;
Students/Postdocs registered prior to September 30, 2009:             Aug 1 to Oct 2, 2009
Students/Postdocs registered after September 30, 2009:                Jan 4 to Feb 5, 2010
PGSS members with exceptional circumstances should contact the PGSS Office without delay.

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