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Health Features and Cost Sheet

OPT-OUT /
HEALTH CARE HCSA ONLY CORE PREMIUM
Deductible None None
No
Out-of-Pocket Maximum Coverage * No Coverage $1,000
(drugs only)
PRESCRIPTION DRUGS
Prescription Drugs 75% (Dispensing fee 90% until Out-of-Pocket reached,
(legally requiring a prescription limited to $8 per prescription) then 100% (Dispensing fee
and mandatory generic) limited to $8 per prescription)
No
Coverage * Fertility: $15,000 / lifetime Fertility: $15,000 / lifetime
Lifestyle Drugs Anti-obesity: Unlimited Anti-obesity: Unlimited
Sexual Dysfunction: $1,200 / year Sexual Dysfunction: $1,200 / year
Sclerotherapy - $40 / visit
PARAMEDICAL SERVICES
Reimbursement 75% 100%
Chiropractor, Naturopath, Massage Chiropractor, Naturopath, Massage
Therapist, Speech Therapist, Therapist, Speech Therapist,
Covered Practitioners
No Osteopath, Podiatrist/Chiropodist, Osteopath, Podiatrist/Chiropodist;
Coverage * Psychological Practitioners Psychological Practitioners OPTIONAL BENEFITS
Maximum, $1500 / year
Psychological Practitioners $500 / year
Combined
Maximum, All Other Practitioners $1200 / year
VISION
Reimbursement 100% 100%
Eye Exams No $75 every 24 consecutive months $75 every 24 consecutive months
Prescription Glasses & Contacts Coverage * $175 every $300 every 24 consecutive months
Laser Eye Surgery 24 consecutive months $3000 / lifetime
HOSPITAL
Reimbursement 100% 100%
Hospital Coverage No Semi-private $175 / day Semi-private $175 / day
Coverage *
Chronic Care No Coverage Semi-private to Private $20 / day,
maximum 180 days per year
OUT-OF-PROVINCE / COUNTRY MEDICAL EMERGENCY
Reimbursement 100% 100%
No
Maximum $1,000,000 / lifetime $1,000,000 / lifetime
Coverage *
Emergency Travel Assistance Included Included
MEDICAL SERVICES & SUPPLIES
Reimbursement 75% 90%
$25,000 / 36 months $25,000 / 36 months
Private Duty Nursing
(reimb. at 100%) (reimb. at 100%)
Hearing Aids $500 / 5 years $500 / 5 years
Wigs $300 / year $300 / year
Surgical Stockings No 2 pairs / year 2 pairs / year
Coverage *
Surgical Bras 2 / year 2 / year
Glucometer $700 / lifetime $700 / lifetime
2 pairs / year 2 pairs / year
Orthopaedic Shoes / Orthotics
(combined max. $1,500 / year) (combined max. $1,500 / year)
Miscellaneous Equipment Included Included
& Supplies
OPT-OUT /
COST HCSA ONLY CORE PREMIUM

Single $0 / per pay $0 / per pay $13.47 / per pay
Single +1 $0 / per pay $0 / per pay $20.41 / per pay
Family (Single + more than 1) $0 / per pay $0 / per pay $26.73 / per pay
* Expense eligible for reimbursement through HCSA

2022 AEO FT HO Book CAN ENG 3.indd 11 2/13/22 9:10 AM