BENEFIT SUMMARY & ENROLLMENT GUIDE

Transcription

1 BENEFIT SUMMARY & ENROLLMENT GUIDE Benefits Enrollment Guide

2 Benefits Enrollment Guide

3 TABLE OF CONTENTS BENEFITS SUMMARY... 3 SUPPLEMENTARY MEDICAL PLAN AT A GLANCE... 5 ELIGIBLE EXPENSES... 5 INELIGIBLE EXPENSES... 5 DRUGS... 6 VISION... 6 HOSPITAL... 6 PARAMEDICAL... 7 MEDICAL SUPPLIES AND SERVICES... 7 OTHER MEDICAL EXPENSES... 8 OUT-OF-COUNTRY EMERGENCY COVERAGE... 9 DENTAL PLAN AT A GLANCE BASIC SERVICES MAJOR RESTORATIVE ORTHODONTIC COORDINATION OF BENEFITS BENEFIT ENROLLMENT GUIDE BEFORE YOU START UNDERSTANDING YOUR PERSONAL BENEFITS REPORT UNDERSTANDING YOUR BENEFITS FORMS COMPLETING THE BENEFITS ENROLLMENT FORM BENEFIT PLANS SUPPLEMENTARY MEDICAL AND DENTAL OPTING OUT COMPANY-PROVIDED PLAN CLAIMS SUBMISSION MAKING YOUR SUPPLEMENTARY MEDICAL AND DENTAL CHOICE EMPLOYEE GROUP LIFE INSURANCE SPOUSE GROUP LIFE INSURANCE COMPLETING THE GROUP LIFE INSURANCE INCREASE FORM CHILD GROUP LIFE INSURANCE EMPLOYEE GROUP ACCIDENTAL DEATH & DISABILITY (AD&D) INSURANCE SPOUSE GROUP ACCIDENTAL DEATH & DISABILITY (AD&D) INSURANCE CHILD GROUP ACCIDENTAL DEATH & DISABILITY (AD&D) INSURANCE SHORT TERM DISABILITY INSURANCE (STD)/SICK LEAVE Employee must work 160 consecutive hours (=4 weeks) w/o absence to reinstate 1040 hours LONG TERM DISABILITY INSURANCE (LTD) BENEFIT FORM SUBMISSION BENEFITS SUMMARY Benefits Enrollment Guide

4 The statements in this document are only a summary of some of the benefits, and their restrictions, provided under the Medical and Dental plan at Husky. The benefits information in this summary does not replace the contract that governs the Medical and Dental program. In the event of a discrepancy between this summary and the contract the latter shall prevail. Supplementary Medical and Dental claims must be submitted within 15 months of the date the expense was incurred. When completing Medical or Dental claim forms you are required to enter your Policy Number, which is 51691, and your Employee Identification Number, which is your Husky Employee Number. If you require information regarding a specific claim for benefits or more detail coverage under the benefits plan, please contact Great West Life at You will be asked to provide your policy and employee identification number as indicated above. Standard Plan Year July 1 to June 30 Eligible Employees Permanent full-time salaried and hourly employees Permanent part-time employees (working on average 15 hours per week) Employees on LTD, parental or personal leaves of absence Ineligible Temporary employees Employees Co-op and summer students Waiting Period Employees are eligible immediately upon hire Tax Status of Benefits Medical and Dental premiums and reimbursements are not taxable to the employee Coverage Categories Definition of Dependent Single Couple/Single with Dependents Married with Dependents Spouse the person with whom you are legally married or a common-law spouse with whom you have lived for a least one year Dependent Child A natural child, stepchild, or legally adopted child of the employee or employee s spouse; under age 21 (or under age 25 if a full time student) unmarried and dependent for support; or any age if physically or mentally incapable of self-support. This definition does not include your spouse s children who do not reside with you. It does, however, include your children, who do not reside with you, but for whom you share financial responsibility. Note: when claiming for vision and certain dental benefits, a child is defined as 18 years of age and under. Over 18 years of age is considered an adult dependent for claiming purposes. Coverage Levels Employee s can choose one of two coverage levels o Company Provided Plan o Opt Out Plan - (if written proof of coverage under a spousal plan or Indian Affairs, is provided) Supplementary Medical and Dental coverage are bundled together, meaning they come as one package. Default Coverage New Hires: If coverage is not selected within 31 days of hire date, the employee will automatically be covered under the Company Provided Plan. Lock-in Once you have selected a Supplementary Medical and Dental option, you are locked-in to that option unless you have a family status change or an employment status change. Benefits Enrollment Guide

5 SUPPLEMENTARY MEDICAL PLAN AT A GLANCE ELIGIBLE EXPENSES ELIGIBLE EXPENSE COMPANY-PROVIDED PLAN Drugs 90% Co-insurance Pay Direct Prescription Drug Card Vision Maximum of $270 per plan year for each child, $270 in any 2 consecutive plan years for adults; and $100 per plan year for an eye exam Hospital 100% Paramedical $900 per plan year per person for combined paramedical Medical Supplies & Services Out-of-Country 100% (plan maximums may apply) $1,000,000 lifetime for employees and dependents NOTE: Opt Out Plan is $1,000,000 lifetime for employee only INELIGIBLE EXPENSES INELIGIBLE EXPENSE COMPANY-PROVIDED PLAN (This is only a partial list of some ineligible expenses please contact Great-West Life Claims to confirm if your claim will be covered) Expenses for the services of a homemaker Expenses for items purchased solely for athletic use Private MRI coverage Travel Vaccines Hearing Tests or Evaluations Breast Pumps (for breast feeding) Pulse Lights are not covered Benefits Enrollment Guide

6 DRUGS Co-insurance COMPANY-PROVIDED PLAN 90% Co-insurance Pay Direct Prescription Drug Card Amount Payable The maximum amount payable for an eligible expense will be limited to the lowest priced item, regardless of brand or generic drug dispensed The Dispensing Fee is capped at $10.00 per prescription Eligible Drugs Drugs which legally require a prescription Life-sustaining drugs which may not legally require a prescription Injectible drugs are eligible if they are medically necessary and prescribed by a doctor, e.g. vitamins, allergy serums and inoculations Compounded prescriptions where one of the ingredients is an eligible expense Needles, syringes, and chemical diagnostic aids for the treatment of diabetes Smoking cessation products, limited to a lifetime maximum of $1,000 Oral contraceptives and the contraceptive drug Norplant Drugs used for the treatment of sclerotherapy (varicose vein treatment) limited to a maximum of $15 per treatment (charges for the doctor to administer the drug are not eligible) Drugs used for the treatment of infertility, limited to a lifetime maximum of $6,000 Drugs for the treatment of erectile dysfunction (expenses for Viagra are limited to $1,000 per year) Anti obesity drug: Zenical (on advice of physician) VISION COMPANY-PROVIDED PLAN Vision Maximum of $270 per plan year for each child, and $270 in any 2 consecutive plan years for adults Frames, lenses and fitting of any type of prescription glasses or contacts Laser eye surgery Eye Exam $100 per year for eye exams HOSPITAL Supplementary Hospital Auxiliary Hospital/ Hospice COMPANY-PROVIDED PLAN 100% private or semi private room and board in excess of ward accommodation, to a maximum of $80 per day Unlimited overall maximum Room and board charges for convalescent or chronic care provided in a licensed hospital Limited to $25 per day to a maximum of 120 days per plan year Benefits Enrollment Guide

7 PARAMEDICAL COMPANY-PROVIDED PLAN Paramedical Combined paramedical services covered at $900 per person per plan year Includes services provided by: Chiropractor, Osteopath, Naturopath, Podiatrist, Physiotherapist, Speech Therapist, Massage Therapist, Acupuncturist, Occupational Therapist, Dietician Psychologist, Master Of Social Work, covered at $1,000 per person per plan year (Reimbursement is subject to limitations stipulated under provincial health care insurance plans) MEDICAL SUPPLIES AND SERVICES Medical Supplies and Services 100% COMPANY-PROVIDED PLAN Trusses and crutches, plaster of paris or fibreglass casts, braces, provided they are not solely for athletic use Artificial limbs or other prosthetic appliances Wigs for cancer patients and other medical conditions limited to $500 lifetime maximum Supplies required as a result of a colostomy or ileostomy Mammary prosthesis following mastectomy, limited to 1 prosthesis per breast every 24 consecutive months to a maximum of $200 per prosthesis Artificial eyes and replacement if required because of a change in physical condition Oxygen, and the equipment necessary for administration Diagnostic laboratory, x-ray examinations, anesthesia and blood transfusions Elastic support stockings limited to a maximum of 2 pair per plan year All diabetic supplies that do not have a DIN if prescribed by a physician, including blood glucose monitors for insulin dependent diabetics Rental, or purchase at the adjudicator s discretion, of durable equipment provided it is prescribed by a physician, including supplies necessary for use with durable equipment. Eligible durable equipment includes, but is not limited to, items such as: Wheelchair purchases and wheelchair repairs: reimbursement on a reasonable and customary basis, i.e. normally 3 years for children and 5 years for adults; special wheelchairs necessary to permit independent participation in daily living are included Walkers Hospital beds Traction kits Benefits Enrollment Guide

8 OTHER MEDICAL EXPENSES COMPANY-PROVIDED PLAN Ambulance 100% Licensed ground and/or air ambulance service to and from the nearest hospital equipped to provide the required treatment when the physical condition of the patient prevents the use of another means of transportation Emergency medical response by paramedics Hearing Aids Maximum of $2,000 per person per 4 consecutive plan years Orthopedics Orthopedic shoes and orthopedic modifications to shoes when they are required for the correction of deformity of the bones and muscles and provided they are not solely for athletic use and are prescribed by a physician, Podiatrist, Chiropodist or Chiropractor, limited to a maximum of $250 per plan year Orthotics as prescribed by a physician, Podiatrist, Chiropodist or Chiropractor, limited to a maximum of $200 per plan year Private-duty $5,000 plan year maximum (services as prescribed by physician) Nursing Services when provided in the patient s home includes RN or LPN involved in direct care activities under physician s direction and/or PCA s involved in activities of daily living and basic health care under the direction of an RN or physician Excluded are housekeeping services, normal childcare, respite care, and services Smoking Cessation Survivor Benefit provided by a spouse or any close relatives Smoking cessation products limited to lifetime maximum of $1,000 per person Includes over the counter products if prescribed by a physician and dispensed at a pharmacy 24 months Benefits Enrollment Guide

9 OUT-OF-COUNTRY EMERGENCY COVERAGE ELIGIBLE EXPENSES Out-of-Country Emergency Coverage Eligible Expenses Global Medical Assistance Benefit Limitations OPT OUT PLAN COMPANY PROVIDED PLAN (Employee Only) (Employee & Dependents) 100% of eligible expenses up to a maximum of $1,000,000 per lifetime per person In the event of a medical emergency, which occurs while the claimant is travelling for a duration no longer than 180 days The following services and supplies are covered, over and above the provincial health plan, when related to the initial medical treatment: Treatment by a physician Diagnostic x-ray and laboratory services Hospital accommodation in a standard or semi-private ward or intensive care unit, if the confinement begins while the person is insured under this benefit provision Medical supplies provided during a covered hospital confinement Paramedical services provided during a covered hospital confinement Hospital out-patient services and supplies Medical supplies provided out-of-hospital if they would have been covered in Canada Drugs which legally require a prescription Out-of-hospital services of a professional nurse Ambulance services by a licensed ambulance company to the nearest centre where essential treatment is available. Alternative benefits are available on the same basis as they are for ambulance services provided in Canada. Assistance is provided through a network that operates 24 hours a day. The network assists in locating medical care and in obtaining the insurance company s prior approval of covered services. The network can also approve on-site hospital payment when required for admission, to a maximum of $1,000. The following services are covered subject to the insurance company s prior approval: Medical evacuation Family assistance Travelling companion Transportation reimbursement Death Unaccompanied minor children Vehicle return Provincial health care plan must be maintained for coverage to be valid Expenses incurred outside of Canada on an elective basis are not payable If the person s medical condition permits a return to Canada, benefits are limited to the lesser of: The amount payable under this policy for continued treatment outside Canada The amount payable under this policy for comparable treatment in Canada plus the cost of return transportation Benefits Enrollment Guide

10 DENTAL PLAN AT A GLANCE ELIGIBLE EXPENSE Basic Major Restorative COMPANY PROVIDED PLAN 90% Co-insurance Combined Basic and Major Restorative maximum of $4,000 per person per plan year Diagnostic & Preventive Minor Restorative Periodontic Endodontic 50% Co-insurance Bridges Dentures Crowns Orthodontic 50% to a lifetime maximum of $3,000 (includes both child and adult orthodontics) Survivor Benefit Dental Services (Accidental) Benefit Limitations 24 months 100% services of a dental surgeon, including dental prosthesis, required for the treatment of a fractured jaw or for the treatment of accidental injuries to natural teeth if the fracture or injury was caused by external, violent and accidental means, provided a detailed treatment plan is received within 12 months of the accident. Services required in conjunction with such fracture or injury due to a condition that existed before the accident is excluded. Reimbursements are subject to the limitations of the provincial dental fee guides; where no fee guide exists, the benefit contract will determine reimbursement amounts. Benefits Enrollment Guide

11 BASIC SERVICES Basic Services 90% Co-Insurance COMPANY PROVIDED PLAN Diagnostic Exam and Diagnosis: oral exam limited exam limited periodontal exam (once per plan year) special oral exam diagnostic casts treatment planning minor emergency treatment consultation house call, institutional call and office visit Tests and Laboratory Examinations: biopsy of oral tissue pulp vitality tests Radiographs: complete series (once per 2 plan years) periapical occlusal bitewing (once per plan year) extraoral sialography radiopaque dyes to demonstrate lesions panoramic (once per 2 plan years) interpretation of radiographs received from another source tomography Laboratory procedures Preventative Preventative Services: dental polishing (once per plan year; twice per plan year for persons age 18 and under) preventative recall package including a combination of recall examination, polishing and/or topical application of fluoride (once per plan year; twice per plan year for persons age 18 and under) topical application of fluoride phosphate (once per plan year; twice per plan year for persons age 18 and under) oral hygiene instruction (once per lifetime) pit and fissure sealants interproximal discing recontouring of teeth for functional reasons Scaling and root planing (not to exceed 9 time units per plan year) Control of oral habits: appliances adjustments, repairs, maintenance Space maintainers and regainers Diagnostic/ Preventative Exclusions Expenses for: cosmetic services the treatment of malocclusion or for orthodontic treatment replacement of space maintainers which have been lost, stolen or mislaid any of the conditions listed on the Dental Provision page as an Exclusion or Limitation Benefits Enrollment Guide

12 BASIC SERVICES Minor Restorative Minor Restorative Minor Restorative Exclusions 90% Co-insurance COMPANY PROVIDED PLAN Plastic fillings: caries control trauma control amalgam acrylic or composite resin transitional restoration of fractured anterior prefabricated restorations Repairs and adjustments porcelain repairs repairs to bridges recementing crowns Periodontics: non surgical services occlusal adjustment/equilibration (not to exceed 8 time units per plan year) Relining and rebasing of dentures Surgical services: uncomplicated removals surgical removals and repositioning surgical excision surgical incision fractures lacerations frenectomy miscellaneous surgical services Drug injections Laboratory procedures Expenses for: cosmetic services the treatment of malocclusion or for orthodontic treatment Benefits Enrollment Guide

13 BASIC SERVICES Periodontic & Endodontic Periodontic Periodontic Exclusions Endodontic Endodontic Exclusions Anesthesia Services 90% co-insurance COMPANY PROVIDED PLAN Periodontics: surgical services post-surgical treatment adjunctive procedures post treatment evaluation Major surgery: Alveoloplasty enucleation of cyst dislocations Laboratory procedures Expenses for: cosmetic services replacement of periodontal appliances which have been lost, stolen or mislaid Endodontics: pulpotomy root canal therapy periapical services other endodontic procedures emergency procedures Laboratory procedures Expenses for cosmetic services Anesthesia (required in relation to covered services) general anesthesia deep sedation conscious sedation services of an Anesthesiologist if required in relation to covered services Benefits Enrollment Guide

14 MAJOR RESTORATIVE MAJOR RESTORATIVE Major Restorative Bridge Bridge Exclusions Denture Denture Exclusions Denture/ Bridge Note 50% Co-insurance COMPANY PROVIDED PLAN Hemisection Fixed bridgework: bridge pontics retainers other prosthetic services Examinations Laboratory procedures Expenses for: cosmetic services crowns and onlays, placed on a tooth not functionally impaired by incisal angle or cuspal damage prosthetic devices which are ordered while the member or covered dependant is covered under this benefit but are installed after termination of this benefit replacement of bridgework except as provided under Eligible Expenses permanent splinting incurring of full mouth reconstructions, for vertical dimension correction or for correction of temporomandibular joint dysfunction Partial and complete dentures Remakes and adjustments Denture Repairs (repairs only) Examinations Laboratory procedures Expenses for: cosmetic services replacement of dentures which have been lost, stolen or mislaid prosthetic devices which are ordered while the member or covered dependant is covered under this benefit but are installed after termination of this benefit replacement of dentures except as provided under Eligible Expenses Replacement of an existing denture or bridgework with a denture, is an eligible expense if the replacement is required to replace an existing denture which was installed at least 3 years before the replacement, limited to a maximum eligible expense of the value and quality of the original denture or bridgework The addition of teeth to an existing partial denture is an eligible expense if the addition is required to replace one or more teeth removed while the member or covered dependant was covered under this benefit. Benefits Enrollment Guide

15 MAJOR RESTORATIVE Co-insurance 50% COMPANY PROVIDED PLAN TMJ Treatment Crown Crown Exclusions Crown Note Expenses incurred for full mouth reconstructions, for vertical dimension correction or for correction of temporomandibular joint dysfunction up to a lifetime maximum of $500 Crowns, inlays, onlays: gold foil restoration metal inlay restorations composite inlay restorations porcelain/ceramic inlay restorations crowns other restorative services Examinations Laboratory procedures Expenses for: cosmetic services crowns and onlays, placed on a tooth not functionally impaired by incisal angle or cuspal damage prosthetic devices which are ordered while the member or covered dependant is covered under this benefit but are installed after termination of this benefit replacement crowns, inlays or onlays except as provided under Eligible Expenses permanent splinting Replacement of an existing crown, inlay or onlay is an eligible expense if the replacement is required to replace an existing crown, inlay or onlay which was installed at least 3 years before the replacement, limited to a maximum eligible expense of the value and quality of the original crown, inlay or onlay ORTHODONTIC ORTHODONTIC Orthodontic Eligible Expenses Orthodontic Exclusions COMPANY PROVIDED PLAN 50% Co-insurance to a lifetime maximum of $3,000 per person Observation, adjustment: oral examination skull and facial bone survey cephalometric radiographs hand and wrist radiographs diagnostic casts surgical services observation, adjustment repairs, alterations active appliances for tooth guidance or uncomplicated tooth movement retention appliances Comprehensive treatment Laboratory procedures Expenses for replacement of orthodontic appliances which have been lost, stolen or mislaid Benefits Enrollment Guide

16 COORDINATION OF BENEFITS If your spouse has a supplementary medical and/or dental plan, you may be able to coordinate benefit claims between Husky s plan and your spouse s plan. The insurance companies have established rules regarding the coordination of benefits. These rules state: You can receive reimbursement from both plans, but the total reimbursement cannot exceed the total amount of the claim. The plan that reimburses for benefits first (primary carrier) will calculate its benefits as though duplicate coverage does not exist. The plan that reimburses benefits second (secondary carrier) limits its benefits to the lesser of: a) The amount that would have been payable had it been the primary carrier, or b) 100% of all eligible expenses reduced by all other benefits payable for the same expenses by the primary plan Any medical or dental claims incurred by you, an employee of Husky, must be submitted to Husky s Supplementary Medical and Dental insurance company first. The claim can then be submitted to your spouse s insurance company for reimbursement of the balance of the claim. Any medical or dental claims incurred by your spouse must be submitted to his/her insurance company for reimbursement first and then submitted to Husky s insurance company for reimbursement of the balance of the claim. To determine the first payer for dependent children claims, the employee whose birthday occurs earlier in the year submits the claims to his/her insurance company first. For example, if your birthday is June 1 and your spouse s is September 2, the children s claims must be sent to Husky s insurance company first and then submitted to your spouse s insurance company for reimbursement of the balance of the claim. If you are divorced or separated, claims for dependent children should be submitted to: the plan of the parent with custody; then to the plan of the spouse of the parent with custody; then to the plan of the parent who does not have custody; and finally, to the plan of the spouse of the parent who does not have custody. Saskatchewan residents must send their dependent children s claims to the government first. The date of birth rule above applies to the remaining balance. If a student has coverage through university, they should submit to that plan first. Husky s insurance carrier may reject a claim if it has not been filed in the proper order. If you plan to submit a claim to more than one plan, make copies of the claim form and the receipts. You will be required to submit them to the second insurer, along with the reimbursement statement from the first insurer. Benefits Enrollment Guide

17 BENEFIT ENROLLMENT GUIDE BEFORE YOU START 1. Gather personal information that may impact your benefits selections, such as coverage available under your spouse's benefits plan and any privately held insurance plans. 2. You may find it useful to have a calculator handy when making your selections and completing forms. 3. Review the Options at Work information and forms in your orientation package: FORM Personal Benefits Report Benefits Enrollment Form Group Life Insurance Increase Form Great West Life - Evidence of Insurability forms PURPOSE Lists all your benefit options and the associated price tag and flex credits. This is a reference for completing the enrollment form(s). Keep this report for your records. Use this form to make your benefit selections, designate beneficiaries, declare smoker status, and authorize. Return the completed form to Human Resources. Complete these forms if you want Employee Group Life Insurance (after 31 days of hire or status change) or Spouse Group Life Insurance above the Company-provided coverage, and return them along with your Benefits Enrollment Form. These options will not be processed until you have obtained approval from Great West Life. UNDERSTANDING YOUR PERSONAL BENEFITS REPORT The Personal Benefits Report lists your available benefits and options. It indicates price tags, flex credits or no cost (on a monthly basis) for each option to assist you with your choices. This is intended to be a worksheet that you may retain for your records. In each benefit option, you will find the Company-provided coverage has been shaded. These are the benefit options in which you will be enrolled if you do not return your Benefits Enrollment Form to Human Resources within 31 days of your hire date. UNDERSTANDING YOUR BENEFITS FORMS There are three forms (as per table above): 1. Benefits Enrollment Form (required) 2. Group Insurance Increase Form (optional depending on coverage chosen) 3. Evidence of Insurability Form (optional depending on coverage chosen) There are four main sections to the Benefits Enrollment Form: 1. Benefit Plan, Option Selection 2. Beneficiary Designation 3. Smoker/Non-Smoker Declaration 4. Authorization Each Benefits Enrollment Form is personalized. The shaded, or Company-provided, options on your Benefits Enrollment Form correspond to the options on your Personal Benefits Report. Benefits Enrollment Guide

18 The Benefits Enrollment Form lists all of your benefit options. The insurance options that require approval from Great West Life are listed on the Group Insurance Increase Form. If you select employee or spouse life insurance above the Company-provided level, check the shaded option on the Benefits Enrollment Form, as this will be your coverage until the increase is approved. Then complete the Group Insurance Increase Form and the corresponding Evidence of Insurability form and return them with the completed Benefits Enrollment Form. COMPLETING THE BENEFITS ENROLLMENT FORM Use the information in your Personal Benefits Report to select an option in every benefit plan. On the front page of the Benefits Enrollment Form, check the option you have selected in each plan. If you are selecting coverage above the Company-provided level for employee or spouse life insurance, you must complete the Group Insurance Increase Form and the applicable Evidence of Insurability form. On the Benefits Enrollment Form, check the shaded or Company-provided level of coverage. You will remain at this level until the optional coverage is approved. If the higher coverage is not approved, you remain at the Company-provided level of coverage. On the front page, you will see two columns to the right of your benefit options: 1. Credits Generated : write in the flex credits for any options you select that have credits 2. Price Tags : write in the price tags for any options you select that have a price tag. You will find the flex credit and price tag amounts in your Personal Benefits Report. When you have selected all of your benefit options, note each total in Row A. This will tell you how many flex credits and price tags you have. If you want to participate in the HCEA you must have generated a minimum of $15.00 per month of flex credits after paying tax-effective price tags. Your credits will first be used to pay tax-effective price tags, which include all the optional AD&D options. You can then direct from $15.00 a month up to the Total Credits Generated in Box A to the HCEA. Designate the amount you want directed to your HCEA in Box B. Any credits remaining should be entered in Box C. HCEA deposits go into your account monthly. Any credits remaining ( Box C ) will be div ided in two and paid to you as taxable cash each pay. Note: What is the HCEA Health Care Expense Account? Your HCEA is an account set up in your name with Great West Life. You are able to use this account throughout the year to pay for expenses that are not covered by your Supplementary Medical or Dental options, your spouse s plan, or by provincial health care. Each July 1, you will be asked whether you want to allocate flex credits to your account. If you direct credits here, throughout the year you can use the HCEA to pay for expenses, as set out by the Canada Customs and Revenue Agency. The tricky thing about an HCEA is knowing how much to put into the account in the first place. Because the HCEA is tax effective, you pay no tax on the monies you allocate to your account, however, there are strict rules in place for its use. The most important rule is the use it or lose it rule. If you do not spend your HCEA account over a two-year period, you lose the balance. So when you allocate HCEA credits, be sure you will have sufficient expenses over the next two years to deplete your account. Otherwise, you forfeit the balance. Benefits Enrollment Guide

19 On the back of the Benefits Enrollment Form, identify your beneficiary(ies) for the Employee Life Insurance and for the Employee Accidental Death and Dismemberment Insurance. If you list multiple beneficiaries indicate the percentage payable to each. The percentages must total 100%. Do not use fractions (i.e. 33.3%). Complete the Smoker/Non-Smoker Declaration section if you have selected Employee Group Life Insurance above two-times your annual base pay. Have your spouse complete the declaration if you have selected Spouse Group Life Insurance above $10,000. Review the information on your Benefits Enrollment Form, sign it, date it, and send it to Human Resources, with all applicable forms as soon as possible. Benefits Enrollment Guide

20 BENEFIT PLANS The following sections provide information on each benefit plan to help you make your selections: SUPPLEMENTARY MEDICAL AND DENTAL There are two Supplementary Medical and Dental options: 1. Opt Out (No coverage) 2. Company-Provided Plan The options are described in greater detail in the Supplementary Medical and Dental Summary document. For this enrollment, you can select any option for Supplementary Medical and Dental, although there are restrictions for opting out. These restrictions are described under Opting Out below. Your Supplementary Medical and Dental coverage category is the same as your family status, indicated on your Personal Benefits Report. You cannot change this coverage unless you change your family status (life event change i.e. marriage, divorce, birth of first child or last child is removed from coverage). Therefore, employees with a family status of couple cannot select single coverage, etc. Flex credits and price tags are also based on your family status. The Supplementary Medical and Dental plan is a bundled benefit. You cannot separate the Supplementary Medical coverage from the Dental coverage. You must choose the same level of coverage for both Medical and Dental Plans; e.g. you cannot elect the Opt Out Plan for Supplementary Medical and the Company-Provided Plan for Dental. The Company-Provided Plan is shaded on the Personal Benefits Report and Benefits Enrollment Form. OPTING OUT You can only opt out of the Supplementary Medical and Dental plan if you have written proof of medical and dental coverage under your spouse's plan. If your family status is single, this option is not available to you except if you have coverage through Indian Affairs. By opting out of the Supplementary Medical and Dental plan, you generate flex credits which you can use to buy higher coverage in other plans, transfer to the Health Care Expense Account and/or take as taxable cash. If you choose to opt out of the Supplementary Medical and Dental plan, there will be out of country coverage for the employee ONLY. COMPANY-PROVIDED PLAN The Company-Provided Plan is 100% paid by Husky. No credits are generated, nor is there a price tag. After this enrollment, you are unable to change your Supplementary Medical and Dental election unless you have a Life event change such as marriage, divorce, birth of first child, last child is removed from coverage or employment status change. Benefits Enrollment Guide

21 CLAIMS SUBMISSION All claims are submitted to Great West Life. Claims must be submitted within 15 months of the date the expense was incurred. The contract number for submitting Medical and Dental claims to Great West Life is This number is pre-printed on both the Health and Dental Claim forms available from Human Resources or your local administrator. If your dentist directly bills Great West Life and you do not use the Husky pre-printed forms, please make sure you inform your dentist of the contract number. MAKING YOUR SUPPLEMENTARY MEDICAL AND DENTAL CHOICE 1. Refer to the Supplementary Medical and Dental Summary document for more detailed information about these options. 2. Select an option from your Personal Benefits Report. 3. If you elect the Company-Provided Plan, check that box on your Benefits Enrollment Form. As this is the company-provided option, there is no price tag and no flex credit. 4. If you elect the Opt Out option, check the box beside the option you have selected. Enter the corresponding flex credits generated, from your Personal Benefits Report onto the Benefits Enrollment Form. 5. If you elect the Opt Out option, send written confirmation from your spouse's employer that you are covered for Medical and Dental under their plan. Please submit this with your Benefits Enrollment Form or as soon as possible. Benefits Enrollment Guide

22 EMPLOYEE GROUP LIFE INSURANCE Employee Life Insurance is designed to provide a lump sum benefit to your beneficiary(ies) in the event of your death. To calculate the benefit, your annual base pay (excludes Bonuses and overtime pay etc..) is multiplied by the option selected and then rounded up to the next thousand dollars. This Plan includes the following options: 1. 1X Annual Base Pay (Minimum $25,000) 2. 2X Annual Base Pay (Company-provided) 3. 3X Annual Base Pay 4. 4X Annual Base Pay 5. 5X Annual Base Pay Optional Benefits Employee paid premium 6. 6X Annual Base Pay 7. 7X Annual Base Pay The Company-provided benefit is 2X your Annual Base Pay. You can reduce your coverage from Company provided 2X to Company provided 1X (releasing flex credits). The premium paid by the company is a taxable benefit to you. This means that the premiums paid by the Company will be taxed as income. The Employee Life Insurance benefit amount cannot be less than $25,000 or greater than $2,000,000. You must provide Evidence of Insurability for any amount over $1,000,000. You can generate flex credits by selecting the 1X option. There are price tags associated with the selection of any option above 2X (Company-provided). The price tags for these options will vary as a function of the option selected your annual base pay, your age band and your smoker status. Note: The age bands are: 34 and under; 35-39; 40-44; 45-49; 50-54; 55-59; 60-64; 65-69; and 70. The price tags and flex credits will change if your salary changes throughout the plan year. If your age band changes during the plan year price tags and flex credits will remain constant until the beginning of the next plan year (July 1 st ). EVIDENCE OF INSURABILITY You can elect the 1X option or Company-provided 2X option without providing Evidence of Insurability, as long as the amount is not over $1,000,000. Evidence of insurability is required if you wish to select coverage above the Company-provided option more than 31 days after hire or after a life event change for employee and child life amounts only (up to $1,000,000). Any future increases would also require Evidence of Insurability, including an increase from 1X to 2X Annual Base Pay. SMOKER/NON-SMOKER STATUS If you are selecting coverage above 2X, be sure to complete the Smoker/Non-Smoker section on your Benefits Enrollment Form. If you change your smoking status during the plan year complete a new declaration form. The Smoker/Non-Smoker rates will change when your status changes. BENEFICIARY(IES) Designate your beneficiary(ies) for this plan in the Beneficiary section. Also indicate the percentage that each beneficiary is to receive. Ensure that the percentages add up to 100%. Do not use fractions. You are able to change beneficiaries at any time by filling in a Beneficiary Change Form which can be printed from the Huskynet website (Corporate/Forms/Human Resources/Health & Benefit Forms) Benefits Enrollment Guide

23 MAKING YOUR LIFE INSURANCE CHOICE 1. Select an option from your Personal Benefits Report. 2. If you elect 2X Annual Base Pay, check that box on your Benefits Enrollment Form. As this is the Company-provided option, there is no price tag and no flex credit. 3. If you elect 1X Annual Base Pay, check that box on your Benefits Enrollment Form. This will generate flex credits. Enter the flex credits from your Personal Benefits Report onto the Benefits Enrollment Form under Credits Generated. 4. If you elect coverage that is higher than the Company-provided 2X (after 31 days from your hire date, life event change or employment status change), you must complete the Life Insurance Increase Form and a Great-West Life Evidence of Insurability for Optional Life Insurance form. On the Benefits Enrollment Form, check the box for the 2X option. Then on the Group Life Insurance Increase Form check the option you want and indicate the corresponding price tag. Benefits Enrollment Guide

24 SPOUSE GROUP LIFE INSURANCE Spouse Life Insurance is available to all eligible employees who have a spouse, as defined in the Supplementary Medical and Dental Summary. This insurance provides a lump sum benefit to you if your spouse should die. This Plan includes the following options: 1. $10,000 (Company-provided) 2. $50, $100, $150, $200, $250, $300, $350, $400,000 Optional Benefits Employee paid premium The Company provided coverage of $10,000 has a flat rate and is not based on your spouse's age or smoker status. You cannot opt out of this plan. There are no price tags or flex credits attached to the Company-provided option; however, the premium paid by the company is a taxable benefit to you. There are price tags associated with any option above $10,000. The price tags for these options will vary as a function of the option selected, your spouse's age band, and smoker status. Note: The age bands are: 34 and under; 35-39; 40-44; 45-49; 50-54; 55-59; 60-64; 65-69; and 70. The Company-provided $10,000 is shaded on your Personal Benefits Report and on your Benefits Enrollment Form. EVIDENCE OF INSURABILITY For this enrollment, you will receive the $10,000 option without providing Evidence of Insurability. Evidence of Insurability is required for coverage greater than the $10,000 option. Any future increases would also require Evidence of Insurability. SMOKER/NON-SMOKER STATUS If you are selecting coverage above $10,000, be sure that your Spouse signs the Smoker/Non-Smoker declaration on your Benefits Enrollment Form. If your spouse changes his/her smoking status during the plan year, he/she must complete a new declaration form. The Smoker/Non-Smoker rates will change when your spouse s status changes. BENEFICIARY(IES) You are automatically the beneficiary of this benefit. Benefits Enrollment Guide

25 MAKING YOUR SPOUSE LIFE INSURANCE CHOICE 1. Select an option from your Personal Benefits Report. 2. If you would like to remain with the $10,000 option, check that box on your Benefits Enrollment Form. As this is the Company-provided option, there is no price tag or flex credit generated. 3. If you elect coverage that is higher than the $10,000 option, you must complete the enclosed Life Insurance Increase Form and a Great-West Life Evidence of Insurability form for Dependent Optional Life Insurance. On the Benefits Enrollment Form check the box for the $10,000 coverage. On the Life Insurance Increase Form check the option you want and indicate the corresponding price tag. Benefits Enrollment Guide

26 COMPLETING THE GROUP LIFE INSURANCE INCREASE FORM You use this form, if you are selecting an option greater than the Company-provided coverage in: Employee Group Life Insurance (Above 2X Annual Base Pay or $1,000,000) over 31 days from date of hire or after a life event change Spouse Group Life Insurance (Above $10,000) This form only lists levels of coverage that are greater than the Company-provided options. The form must be completed and returned with your Benefits Enrollment Form, under the following circumstances: If you are selecting higher Employee Group Life coverage, check the box corresponding to the level of coverage you want. From your Personal Benefits Report, enter the price tag amount. Complete an Evidence of Insurability form for Optional Life Insurance and attach it to the Group Life Insurance Increase Form. Send both forms to Human Resources with your Benefits Enrollment Form. If you are selecting higher Spouse Group Life coverage, check the box corresponding to the level of coverage you want. From your Personal Benefits Report, enter the price tag amount. Have your spouse complete the Evidence of Insurability form and attach it to the Group Life Insurance Increase Form. Send both forms to Human Resources with your Benefits Enrollment Form. Once Great West Life approves the increase for any of the above insurance, Human Resources will make the change and send you a revised Confirmation Statement for your files. Benefits Enrollment Guide

27 CHILD GROUP LIFE INSURANCE Child Life Insurance is available to all eligible employees with dependent children, as defined in the Supplementary Medical and Dental Summary. This insurance provides a lump sum benefit to you, if an insured dependent child should die. This plan includes the following three options: 1. $10,000 (Flex credits released) 2. $15,000 (Company-provided) 3. $30,000 (Optional Benefit Employee paid premium) The Company-provided benefit is the $15,000 option. You cannot opt out of this plan. The Companyprovided coverage has no price tag or flex credits, however, the premium paid by the company is a taxable benefit to you. Each dependent child has the same level of coverage. Once a specific coverage level is in place, additional future children are automatically covered at the same coverage level. There are flex credits generated with the selection of the $10,000 option. The flex credits for this option are the same, regardless of the number of children. There are price tags associated with the selection of the $30,000 option. The price tag for this option are the same, regardless of the number of children. The Company-provided $15,000 is shaded on your Personal Benefits Report and on your Benefits Enrollment Form. EVIDENCE OF INSURABILITY For this enrollment, you can elect any option without providing Evidence of Insurability. Any future increases would require Evidence of Insurability, except for the birth of your first child. BENEFICIARY(IES) You are automatically the beneficiary of this benefit. MAKING YOUR CHILD LIFE INSURANCE CHOICE 1. Select an option from your Personal Benefits Report. 2. If you elect the $15,000 option, check that box on the Benefits Enrollment Form. As this is the Company-provided option, there is no price tag or flex credit generated. 3. If you are selecting the $10,000 option, check that box on your Benefits Enrollment Form and enter the flex credits from your Personal Benefits Report onto the Benefits Enrollment Form. 4. If you are selecting the $30,000 option, check that box on your Benefits Enrollment Form and enter the price tag from your Personal Benefits Report onto the Benefits Enrollment Form. Benefits Enrollment Guide

28 EMPLOYEE GROUP ACCIDENTAL DEATH & DISABILITY (AD&D) INSURANCE Employee Group AD&D Insurance protects you or your beneficiary(ies) from the financial burden resulting from an accident. Benefits are paid in the event of your accidental death or in the event of accidental loss of limbs, sight, hearing or mobility. This plan includes the following options: 1. 1X Annual Base Pay 2. 2X Annual Base Pay 3. 3X Annual Base Pay (Company-provided) 4. 4X Annual Base Pay 5. 5X Annual Base Pay Optional Benefit Employee paid premium 6. 6X Annual Base Pay 7. 7X Annual Base Pay The Company-provided benefit is 3X your Annual Base Pay. You cannot opt out of this plan. There are no price tags or flex credits associated with the Company-provided option. The minimum insurance amount is $25,000, and the maximum amount is $1,500,000. There are flex credits generated by selecting the 1X or 2X coverage options. There are price tags associated with all options above 3X. The price tags for these options will vary as a function of your annual base pay and the option selected. Evidence of Insurability is not required for any of the options in this plan. If your pay changes throughout the plan year, your price tags will change automatically. The Company-provided 3X coverage is shaded on your Personal Benefits Report and on your Benefits Enrollment Form. BENEFICIARY(IES) Designate your beneficiary(ies) for this plan in the Beneficiary section. Also indicate the percentage that each beneficiary is to receive. Ensure that the percentages add up to 100%. Do not use fractions. MAKING YOUR AD&D INSURANCE CHOICE 1. Select an option from your Personal Benefits Report. 2. If you elect 3X Annual Base Pay, check that box on your Benefits Enrollment Form. As this is the Company-provided option, there is no price tag and no flex credits are generated. 3. If you elect coverage at 1X or 2X Annual Base Pay, check the appropriate box on the Benefits Enrollment Form. Enter the flex credits from your Personal Benefits Report onto the Benefits Enrollment Form. 4. If you elect coverage above 3X, check the appropriate box on the Benefits Enrollment Form. Enter the price tag from your Personal Benefits Report onto the Benefits Enrollment Form. Benefits Enrollment Guide

29 SPOUSE GROUP ACCIDENTAL DEATH & DISABILITY (AD&D) INSURANCE Spouse Group AD&D Insurance is available to all eligible employees who have a spouse, as defined in the Supplementary Medical and Dental Summary. Benefits are paid in the event of your spouse's accidental death and also in the event of the accidental loss of limbs, sight, hearing or mobility. This plan includes the following options: 1. No Coverage 2. $50, $250, $100, $300, $150, $350, $200, $400,000 All of these options, except No Coverage, have price tags as the Company does not provide any Spouse Group AD&D Insurance. Evidence of Insurability is not required for any of the options in this plan. The No Coverage option is shaded on the Personal Benefits Report and Enrollment form. BENEFICIARY(IES) You are automatically the beneficiary of this benefit. MAKING YOUR SPOUSE AD&D CHOICE 1. Select an option from your Personal Benefits Report. 2. If you elect No Coverage, check that box on your Benefits Enrollment Form. 3. If you elect coverage, check the appropriate box on the Benefits Enrollment Form. Enter the price tag from your Personal Benefits Report onto the Benefits Enrollment Form. Benefits Enrollment Guide

30 CHILD GROUP ACCIDENTAL DEATH & DISABILITY (AD&D) INSURANCE Child Group AD&D Insurance is available to all eligible employees who have children, as defined in the Supplementary Medical and Dental Summary. Benefits are paid in the event of your child's accidental death and also in the event of the accidental loss of limbs, sight, hearing or mobility. This plan includes the following options: 1. No Coverage 2. $5, $10, $25, $50,000 All of these options, except No Coverage have price tags as the Company does not provide any Child Group AD&D Insurance. The price tags for these options are the same regardless of the number of children you have. Evidence of Insurability is not required for any of the options in this plan. The No Coverage option is shaded on your Personal Benefits Report and on your Benefits Enrollment Form. BENEFICIARY(IES) You are automatically the beneficiary of this benefit. MAKING YOUR CHILD AD&D CHOICE 1. Select an option from your Personal Benefits Report. 2. If you elect No Coverage, check that box on your Benefits Enrollment Form. 3. If you elect coverage, check the appropriate box on your Benefits Enrollment Form. Enter the price tag from your Personal Benefits Report onto the Benefits Enrollment Form. Benefits Enrollment Guide

31 SHORT TERM DISABILITY INSURANCE (STD)/SICK LEAVE Short term disability is self insured by Husky to provide salary continuance while on sick leave. A full time employee is eligible for 1040 hours (26 weeks) of salary continuance. This is also considered the waiting period into Long Term Disability (LTD). For temporary absences due to illness or injury, you may be eligible for a percentage of your pay, up to a maximum of 1,040 hours (approximately 26 weeks) per year. The amount you receive depends upon your years of service as follows (prorated for part-time based on working percentage): Service Benefit 100% of Pay Benefit 66 2/3% of Pay Up to 1 year 240 work hours 800 work hours 1 year 400 work hours 640 work hours 2 years 640 work hours 440 work hours 3 years 800 work hours 240 work hours 4 years or more 1040 work hours 0 work hours Employee must work 160 consecutive hours (=4 weeks) w/o absence to reinstate 1040 hours. Benefits Enrollment Guide

32 LONG TERM DISABILITY INSURANCE (LTD) Long Term Disability (LTD) Insurance provides a monthly income replacement benefit if you are sick or disabled for a period lasting longer than 26 weeks or (1040 hours). If disability is approved and commences prior to age 64 benefits will not be payable beyond age 65. In the event an approved disability commences after age 64, benefits will not be payable beyond 2 years. Regardless of date of approved disability, LTD benefits will not be extended beyond age 70. The Company provided option is 70% taxable. There are no flex credits or price tags associated with the Company-provided option. Alternatively, employees can choose the following option: 60% + COLA Non-Taxable (This is calculated using a step formula 60% of first $4,000 monthly base salary, 50% of second $4,000 of monthly salary & 45% of remaining monthly salary.) The non-taxable option has a flex credit and a price tag associated with them. This is because you must pay the full cost of the coverage with after-tax payroll deductions, and you are given the cost of the Company-provided 70% option in pre-tax flex credits. The 60% + COLA Taxable plan has a price tag because it is of higher value than the 70% Company-provided benefit. The monthly LTD benefit cannot exceed $20,000 per month. If your pay changes throughout the plan year your flex credits and price tags will change automatically. Taxable Plan Employer pays premium and tax is deducted from monthly income if the employee goes on LTD. Non-Taxable Plan Employee pays premium and no tax is deducted from the monthly income if the employee goes on LTD. The Company-provided 70% Taxable plan has been shaded on your Personal Benefits Report and on your Benefits Enrollment Form. Benefits Enrollment Guide

33 EVIDENCE OF INSURABILITY For 31 days after you first join Husky or for 31 days after a life event change, you can elect any option without providing Evidence of Insurability. However, to insure for a monthly benefit over $12,000 you will need medical evidence at all times. In the future, any time you increase your LTD coverage, you must provide Evidence of Insurability. For example, if you elect the 70% coverage and then increase to the 60% + COLA options you must provide Evidence of Insurability. MAKING YOUR LTD CHOICE 1. Select an option from your Personal Benefits Report. 2. If you elect the 70% Taxable Company-provided option, check that box on your Benefits Enrollment Form. As this is Company-provided, there is no price tag and no flex credits are generated. 3. If you elect the 60% + COLA Non-Taxable option, check that box on the Benefits Enrollment Form. There is a price tag and flex credits. Enter the flex credits and the price tag from your Personal Benefits Report onto your Benefits Enrollment Form. You must pay the full price tag for this option with after-tax payroll deductions. At age 64.5, coverage will continue under the Husky paid 70% taxable LTD plan. Affected employees not already enrolled in this plan will automatically be transferred at age % LTD coverage will remain in force to age 69.5, provided you remain actively employed with Husky. No benefits will be payable beyond age 70. If a disability occurs before moving to the 70% Husky paid plan, benefit payments will continue, based on the plan in effect at the time of the disability, to the greater of age 65 or 24 months. Benefits Enrollment Guide

34 BENEFIT FORM SUBMISSION ONCE YOU HAVE COMPLETED YOUR FORMS 1. Review your choices with your family (if applicable). 2. Check your calculations. BENEFIT FORMS 1. Make a copy of your Benefits Enrollment Form, and any other forms applicable to the selections you have made and keep them in your Enrollment Package folder. When you receive your Confirmation Statement, check it against the copies you kept to ensure the entries are accurate. 2. Remember to submit a letter from your spouse's employer, if you are opting out of the Supplementary Medical and Dental plan confirming duplicate coverage. 3. Keep your Personal Benefits Report and Supplementary Medical and Dental Summary document, for future reference, in your Enrollment Package folder. SUBMIT ORIGINAL FORMS TO HUMAN RESOURCES AS SOON AS POSSIBLE. Benefits Enrollment Guide