For complete details on the SGA Health Plan, please visit the website below!
One eye examination, by an ophthalmologist or optometrist, registered and legally practicing within the scope of his or her license is covered. No amount will be paid for contact lens fitting fee.
Foot Care: 50%, up to $200 per student year (Referral Required)
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 when required to correct a diagnosed physical impairment and when recommended by a
licensed doctor (M.D.).
Accidental Dental: $1,000 per student year
Charges for dental services by a licensed dentist for the repair of sound natural teeth (healthy, non-diseased and not heavily restored) are covered 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 or to existing dentures, crowns, or bridgework.
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.
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. Our 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 Campus Trust.
Our Plan covers a list of prescription drugs, professionally compiled to address the needs of students. The “Student Managed Drug Formulary” is designed to help reduce the cost of the Plan while maintaining comprehensive quality care and benefits.
Eligible drugs including those within the following general categories: (1) eligible drugs which by law require a prescription for purchase; (2) compound mixtures where one of the ingredients is an eligible item.
It should be noted that drugs are only considered eligible if they were prescribed by a licensed doctor (M.D.) or licensed dentist, or another professional, authorized by provincial legislation to prescribe drugs, and dispensed by a registered pharmacist or licensed doctor (M.D.).
The only drugs not legally requiring a prescription which will be reimbursed if accompanied by an official prescription receipt from the pharmacist are: vaccines/serums (only if course requirement, authorization by school required); insulin; diabetic supplies: insulin syringes and needles;
diagnostic reagents for the diagnosis and monitoring of diabetes; lancets.
Specifically excluded from coverage, whether legally requiring a prescription or not, are: all smoking cessation products; fertility drugs; prescription mouthwashes; hair loss and hair growth agents; vitamins (other than injectible); dietary foods I supplements; household products such as, but not limited to, soap and toothpaste; oral drugs for the treatment of erectile dysfunction.
Tutorial Expenses: $15 per hour, up to $1, 000 per disability
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, up to the Benefit Maximum. The teacher must be approved, in advance, by the Students’ Council. 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 normal activities a person of the same age or sex.
Lenses and frames or contact lenses, when prescribed by an ophthalmologist or optometrist, are covered. Laser eye surgery; in lieu of lenses and frames, will also be covered, up to the Benefit Maximum. No amount will be paid for non-prescription glasses, such as safety or sunglasses, anti-reflective coatings or for tints.
Charges for licensed ambulance service are covered in excess of the amount payable under the covered person’s Provincial Health Care Plan.
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.
Services provided by the following Health Practitioners, are covered when the provider is registered and legally practicing within the scope of his/her license:
Acupuncturist, Chiropractor, Counselling by a Psychologist or Registered Social Worker, Dietitian/Nutritionist, Massage Therapist, Naturopath Consultations, Osteopath, Occupational Therapist, Physiotherapist, Podiatrist/Chiropodist, Speech Therapist
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.
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.
These are procedures used to treat or help prevent basic dental problems. Some of the procedures are examinations and x-rays.
Examinations: Initial or Complete Examinations (1 exam per student year), Recall Examinations (1 exam per student year), Specific Examinations, Emergency Examinations
X-Rays: Full Mouth Series X-rays (1 time in a 3 year period for dependents age 12 or older), Periapical X-rays (total of 16 films in a 3 year period), Bitewing X-rays ( total of 4 films in a student year), Panoramic X-rays (1 time in a 3 year period)
Cavity Prevention: Polishing or Cleaning Teeth (2 units per student year), Recall Scaling (2 units at 100% – 6 units at 80% per student year), Pit and Fissure Sealants (1 time in a 3 year period for dependents age 16 or younger)
Space Maintainers: 1 per space for dependants age 14 or younger
Procedures include local anesthesia, removal of decay, pulp protection and bite adjustment.
Fillings: Sedative, Silver and White Fillings Retentive Pins
Endodontics and Periodontics: 75%
Procedures include root canals, root planing and management of oral disease.
Endodontic: Pulpotomy, Root Canal (1 time per tooth)
Periodontic: Oral Disease, Desensitization, Gingival Curettage, Gingivectomy, Flap Surgery, Tissue Graft, Root Planing
Oral Surgery: 75%
Procedures include local anesthesia, appropriate x-rays, surgery and follow-up care.
Minor: Extractions, Erupted Teeth, Residual Root Removal
Major: Extractions, Surgical, Alveoloplasty, Gingivoplasty, Stomatoplasty, Vestibuloplasty Surgical Excision/Incision, Fractures, Frenectomy, Post Surgical Care
Includes General Anesthesia, Deep Sedation, Inhalation Technique, Intravenous Sedation
No amount will be reimbursed for the following expenses: crowns, bridges, dentures, bite plates, major restorative, 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; 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 (Jaw); endodontic treatment that started before the effective date of coverage dental appliances; 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); implanting fabricated teeth or any major surgery resulting from implanting fabricated teeth.
How to Claim
Claims must be submitted within 6 months of the date of loss. If the Plan terminates, claims must be submitted within 3 months from the termination date. Legal action to recover benefits must begin within 2 years of the date of loss.
Your personalized Benefits Card can be printed from www.studentbenefits.ca under the Download Centre, once you have completed the online registration. The card should be presented to your pharmacist (along with your prescription) and/or dental office, in order to access the Pay-direct system. Your claim is processed immediately without the need for you to mail in a claim form.
All other benefits are paid on a reimbursement basis. To make a claim you have two options:
(1) Mail in a completed claim form (forms available online at www.studentbenefits.ca or from the Campus Administrator) along with receipts to The Campus Trust. For dental claims, a standard dental claim form can be obtained from your dental office. Remember to complete each section of the claim form in full including your Student ID and correct mailing address.
(2) Online Claim Submission is an easy and practical way to submit for reimbursement. You must log in to Member Registration in order to access the Online Claim Submission form. For more details, visit www.studentbenefits.ca. You are responsible for retaining original claim receipt(s) for 12 months following the date of your online claim submission(s). The Campus Trust may request the original receipts at anytime within the 12 months following your submission.
Your plan allows you to assign your benefits to a provider. When you assign your benefits, the Explanation of Benefits (EOB) is mailed to the provider only. When a provider is submitting a claim on your behalf, the claim must include an Assignment of Benefits form, found on studentbenefits.ca under the Download Centre, an invoice, and a Doctor’s referral (if applicable). You must review and sign the Assignment of Benefits form to ensure accuracy before the claim is submitted, on your behalf, by your service provider.
You are responsible to ensure that you are eligible for coverage on the date of your treatment. No amount will be paid if your coverage is not in effect at the time of treatment.
Remember that all benefits have limits, and not all providers will accept direct billing. You should ask your provider if they will direct bill before starting treatment.
You and your eligible dependants can purchase prescription drugs and dental services using Pay-direct.
Remember that all benefits have limits and some pharmacists and dental offices do not submit claims electronically.
In order to make a claim, the card should be presented to your pharmacist or dental office at the time of expense, in order to access the Pay-direct system. Your claim is processed immediately; eliminating the need for you to mail in a paper claim form.
In the case of a claim for you, the student, this plan is the first payer and the dependant coverage available through your other plan is the second payer. In the case of your spouse’s claim, our plan is the second payer if they have their own plan.
For dependant children, claims are submitted first to the benefit plan for the parent whose birthday (month and day) occurs earlier in the calendar year, regardless of age.
Following the reimbursement from the first payer, copies of the receipts and the Explanation of Benefits must be submitted to the other plan so that the balance can be considered for payment.
If your health care practitioner does not accept your benefits card you are required to pay up front and submit your receipt for reimbursement at studentbenefits.ca.
How to Opt Out
Simply visit studentbenefits.ca and select the SGA Plan, then follow directions to Opt Out and receive a refund.