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Association Plan

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	Age 18 ans	Region
Adult 1		Quebec Ontario
Adult 2

Age 18 ans

Region

Adult 1

Quebec

Ontario

Adult 2

	Age under 21
Child 1		Child 2
Child 3		Child 4

Your monthly
premium

	Base Plan	Bronze Plan	Silver Plan	Gold Plan
Comprehensive plans	N/A	N/A	N/A	N/A
Dental Plans	N/A	N/A	N/A	N/A

Base Plan

Bronze Plan

Silver Plan

Gold Plan

Comprehensive plans

N/A

Dental Plans

N/A

Summary of benefits	Base Plan	Bronze Plan	Silver Plan	Gold Plan
Dental Services Dental Services Covers basic services, paid at a percentage of the current Dental Association Fee Schedule or the reasonable and customary charge in your province of residence.	Basic Services - Max. $400 per year Dental Services Reimbursement 70% on Basic Services : Exams, cleanings, fillings, scaling, polishing, root planing, diagnostic, select extractions and other basic dental services Reimbursement on extensive services including oral surgery, endodontics, periodontics and denture services	Bsic Services - Max. $500 per year Dental Services Reimbursement 80% on Basic Services : Exams, cleanings, fillings, scaling, polishing, root planing, diagnostic, select extractions and other basic dental services Reimbursement on extensive services including oral surgery, endodontics, periodontics and denture services	Basic Services - Max. Year 1: $500; Max. Year 2 and beyond: $900 Dental Services Reimbursement 80% on Basic Services : Exams, cleanings, fillings, scaling, polishing, root planing, diagnostic, select extractions and other basic dental services Reimbursement on extensive services including oral surgery, endodontics, periodontics and denture services	Basic and Major services - Maximum : Year 1: $750; Year 2: $1,000; Year 3: $1,200; Year 4: $1,200; Year 5 and beyond: $1,500 Dental Services Basic Services - Reimbursement 80% : Exams, cleanings, fillings, scaling, polishing, root planing, diagnostic, select extractions and other basic dental services Reimbursement on extensive services including oral surgery, endodontics, periodontics and denture services Major Services : Reimbursement 60% after 2 years of insurance. Crowns, bridges, dentures and orthodontics
PRESCRIPTION DRUGS	Generic - Maximum $525 per year Reimbursment 70% of the first $750 of drugs	Generic - Maximum $2,350 per year Reimbursment 70% of the first $750 of drugs and 80% of the next $2,500	Generic - Maximum $2,350 per year Reimbursment 70% of the first $500 of drugs and 100% of the next $4,650	Brand-name - Maximum $10,000 per year Reimbursment 90% of the first $2,222 of drugs and 100% of the next $8,000
Vision care Covers the costs towards prescription lenses and frames and/or contact lenses. This benefit does not include industrial safety glasses.	$100 per 2 benefit years $50 for Optometrist visits per 2 benefit years	$100 per 2 benefit years $50 for Optometrist visits per 2 benefit years	$150 per 2 benefit years $50 for Optometrist visits per 2 benefit years	$250 per 2 benefit years $50 for Optometrist visits per 2 benefit years
Hospital Benefits Preferred hospital accommodation in excess of the standard ward room rate made by a general (acute care) hospital. Also included is a cash benefit in lieu of the room cost for each day you are not able to obtain preferred accommodation.	N/A	N/A	Semi-private only Maximum $150 per day Reimbursement per anniversary year : 100% of first 30; 50% of next 100 days Cash benefit in lieu of accommodation Per day : $25 payable starting on the 4th day - Maximum : $750	Semi-private and private Maximum $200 per day Reimbursement per anniversary year : 100% of complete year Cash benefit in lieu of accommodation Per day : $50 payable starting on the 1th day - Maximum : $3,000
Accidental Death and Dismemberment Accidental Death and Dismemberment Payment for a loss directly resulting from accidental bodily injury or accidental loss of life, where the loss occurs within a year of the date of the accident.	$10,000 per adult under 65 $4,000 per child or per adult 65 and older	12,500 per adult under 65 $5,000 per child or per adult 65 and older	$25,000 per adult under 65 $10,000 per child or per adult 65 and older	$50,000 per adult under 65 $20,000 per child or per adult 65 and older
Travel Coverage (up to age 65) Travel Coverage Covers emergency hospital/medical expenses while travelling outside your province or territory of residence and access to a 24-hour worldwide medical assistance centre up to a maximum of $5,000,000 per trip.	Max. trip length - 5 days	Max. trip length - 9 days	Max. trip length - 17 days	Max. trip length - 30 days
Survivor Benefit	Available 1 year after policy effective date	Covered	Covered	Covered
Health Service Navigator	Covered	Covered	Covered	Covered
Lifeline® Personal Response Service	3 months per lifetime	3 months per lifetime	6 months per lifetime	6 months per 3-year period
Registered Specialists and Therapists Registered Specialists and Therapists Includes visits to Acupuncturists, Chiropractors, Osteopaths, Podiatrists, Naturopaths, Chiropodists, Registered Massage Therapists, Physiotherapists, Psychologists, Social Workers and Speech Therapists. Registered Specialists and Therapists.	$300 per specialist/therapist	80% to a maximum of $450 per specialist/therapist	90% to a maximum of $600 per specialist/therapist	$600 combined
Psychologist /Social Worker	10 visits per year Maximum per first visit $80 and per subsequent visit $65	10 visits per year Maximum per first visit $80 and per subsequent visit $65	12 visits per year Maximum per first visit $80 and per subsequent visit $65	15 visits per year Maximum per first visit $80 and per subsequent visit $65
Speech Therapist	10 visits per year Maximum per first visit $65 and per subsequent visit $45	10 visits per year Maximum per first visit $65 and per subsequent visit $45	12 visits per year Maximum per first visit $65 and per subsequent visit $45	15 visits per year Maximum per first visit $65 and per subsequent visit $45
CAT scans annual maximum CAT scans Expenses incurred when required for diagnosis or treatment of an illness or injury, when prescribed or requested by attending Physician.	$200	$200	$200	$200
CA 125 test annual maximum CA 125 test Towards the expense of testing required for the diagnosis or treatment of an illness, when prescribed or requested by the attending Physician.	$75	$75	$75	$75
PSA test annual maximum PSA test Towards the expense of testing required for the diagnosis or treatment of an illness, when prescribed or requested by the attending Physician.	$75	$75	$75	$75
Ultrasound Scans annual maximum Ultrasound Scans The cost incurred when performed in a private office.	$50	$50	$50	$50
Magnetic Resonance Imaging annual maximum Magnetic Resonance Imaging Expenses incurred when required for diagnosis or treatment of an illness or injury, when prescribed or requested by attending Physician.	$500	$500	$500	$500
Audiologist Charges for services rendered	$500 annual maximum	$500 annual maximum	$500 annual maximum	$500 annual maximum
Laboratory Tests annual maximum Laboratory Tests Expenses for blood tests, urine tests and throat cultures required as a result of an accident or for the diagnosis or treatment of an illness.	$100 per category	$100 per category	$100 per category	$100 per category
Homecare and Nursing, Prosthetic Appliances and Durable Medical Equipment Homecare and Nursing, Prosthetic Appliances and Durable Medical Equipment Covers the services of a Registered Nurse, Registered Practical Nurse, Certified Home Support Worker, Occupational Therapist or Registered Dietitian; includes surgical bandages and dressings and the purchase or rental of medically necessary equipment such as crutches, non-electric wheelchairs and hospital beds, oxygen and other equipment recommended by your physician and approved by Manulife Financial. Also includes prosthetic appliances such as artificial limbs, eyes, splints, casts and breast prostheses following mastectomies. Payment will be coordinated where benefits are available through the Assistive Devices Program.	For each of Homecare and Nursing, Prosthetic Appliances and Durable Medical Equipment: Year 1: $1,000 Year 2: $1,300 Year 3: $1,500 Year 4: $2,000 Year 5+: $2,500 Custom-made Orthotics: $225 per year	Homecare and Nursing: $2,500 per year Prosthetic Appliances: $2,500 per year Durable Medical Equipment: $2,500 per year Custom-made Orthotics: $225 per year	Homecare and Nursing: $3,500 per year Prosthetic Appliances: $3,500 per year Durable Medical Equipment: $3,500 per year Custom-made Orthotics: $225 per year	Combined maximum for Homecare and Nursing, Prosthetic Appliances and Durable Medical Equipment $8,500 per year Custom-made Orthotics: $225 per year
Hearing Aids Hearing Aids Covers the cost to purchase and/or repair up to the allowed maximum.	$300 per 4-year period	$300 per 4-year period	$400 per 4-year period	$500 per 4-year period
Ambulance Services Ambulance Services Covers trips to hospitals in a licensed ambulance. Covers charges up to the amount between what your provincial health plan covers and what is reasonable and customary.	Unlimited ground transport $4,000 maximum air ambulance	Unlimited ground transport $4,000 maximum air ambulance	Unlimited ground transport $4,000 maximum air ambulance	Unlimited ground transport $4,000 maximum air ambulance
Accidental Dental Accidental Dental Covers dental treatment required as a result of an accidental blow to the head or mouth. Treatment must be sought within the 90-day period following the accident.	$2,000 per year	$2,000 per year	$2,500 per year	$3,000 per year
Lifetime Maximum	$100,000	$250,000	$350,000	$350,000
	Information purposes only.

Summary of dental benefits	Base Dental Plan	Bronze Dental Plan	Silver Dental Plan	Gold Dental Plan
Dental Services Dental Services Covers basic services, paid at a percentage of the current Dental Association Fee Schedule or the reasonable and customary charge in your province of residence.	Basic Services - Max. $400 per year Dental Services Reimbursement : Year 1: 50%; Year 2 and beyond: 70% Basic Services : Exams, cleanings, fillings, scaling, polishing, root planing, diagnostic, select extractions and other basic dental services Reimbursement on extensive services including oral surgery, endodontics, periodontics and denture services	Bsic Services - Max. $500 per year Dental Services Reimbursement : Year 1: 50%; Year 2 and beyond: 70% Basic Services : Exams, cleanings, fillings, scaling, polishing, root planing, diagnostic, select extractions and other basic dental services Reimbursement on extensive services including oral surgery, endodontics, periodontics and denture services	Basic Services - Max. Year 1: $500; Max. Year 2 and beyond: $900 Dental Services Reimbursement : Year 1: 60%; Year 2 and beyond: 80% Basic Services : Exams, cleanings, fillings, scaling, polishing, root planing, diagnostic, select extractions and other basic dental services Reimbursement on extensive services including oral surgery, endodontics, periodontics and denture services	Basic and Major services - Maximum : Year 1: $750; Year 2: $1,000; Year 3: $1,200; Year 4: $1,200; Year 5 and beyond: $1,500 Dental Services Basic Services - Reimbursement: Year 1: 60%; Year 2 and beyond: 80% Exams, cleanings, fillings, scaling, polishing, root planing, diagnostic, select extractions and other basic dental services Reimbursement on extensive services including oral surgery, endodontics, periodontics and denture services Major Services : Reimbursement 60% after 2 years of insurance. Crowns, bridges, dentures and orthodontics
PRESCRIPTION DRUGS	N/A	N/A	N/A	N/A
Vision care Covers the costs towards prescription lenses and frames and/or contact lenses. This benefit does not include industrial safety glasses.	$100 per 2 benefit years $50 for Optometrist visits per 2 benefit years	$100 per 2 benefit years $50 for Optometrist visits per 2 benefit years	$100 per 2 benefit years $50 for Optometrist visits per 2 benefit years	$100 per 2 benefit years $50 for Optometrist visits per 2 benefit years
Hospital Benefits	N/A	N/A	N/A	N/A
Accidental Death and Dismemberment Accidental Death and Dismemberment Payment for a loss directly resulting from accidental bodily injury or accidental loss of life, where the loss occurs within a year of the date of the accident.	$10,000 per adult under 65 $4,000 per child or per adult 65 and older	$10,000 per adult under 65 $4,000 per child or per adult 65 and older	$10,000 per adult under 65 $4,000 per child or per adult 65 and older	$10,000 per adult under 65 $4,000 per child or per adult 65 and older
Travel Coverage (up to age 65)	N/A	N/A	N/A	N/A
Survivor Benefit Survivor Benefit Provides continuous coverage for 1 year, following the death of an adult Insured.	Available 1 year after policy effective date	Available 1 year after policy effective date	Available 1 year after policy effective date	Available 1 year after policy effective date
Health Service Navigator Health Service Navigator Covers dental treatment required as a result of an accidental blow to the head or mouth. Treatment must be sought within the 90-day period following the accident.	Covered	Covered	Covered	Covered
Lifeline® Personal Response Service	3 months per lifetime	3 months per lifetime	3 months per lifetime	3 months per lifetime
Registered Specialists and Therapists Registered Specialists and Therapists Includes visits to Acupuncturists, Chiropractors, Osteopaths, Podiatrists, Naturopaths, Chiropodists, Registered Massage Therapists, Physiotherapists, Psychologists, Social Workers and Speech Therapists. - Maximum 300$ per specialist and 20$ per visit	300$ per specialist and 20$ per visit	300$ per specialist and 20$ per visit	300$ per specialist and 20$ per visit	300$ per specialist and 20$ per visit
Psychologist /Social Worker	10 visits per year Maximum per first visit $80 and per subsequent visit $65	10 visits per year Maximum per first visit $80 and per subsequent visit $65	10 visits per year Maximum per first visit $80 and per subsequent visit $65	10 visits per year Maximum per first visit $80 and per subsequent visit $65
Speech Therapist	10 visits per year Maximum per first visit $65 and per subsequent visit $45	10 visits per year Maximum per first visit $65 and per subsequent visit $45	10 visits per year Maximum per first visit $65 and per subsequent visit $45	10 visits per year Maximum per first visit $65 and per subsequent visit $45
CAT scans annual maximum CAT scans Expenses incurred when required for diagnosis or treatment of an illness or injury, when prescribed or requested by attending Physician.	$200	$200	$200	$200
CA 125 test annual maximum CA 125 test Towards the expense of testing required for the diagnosis or treatment of an illness, when prescribed or requested by the attending Physician.	$75	$75	$75	$75
PSA test annual maximum PSA test Towards the expense of testing required for the diagnosis or treatment of an illness, when prescribed or requested by the attending Physician.	$75	$75	$75	$75
Ultrasound Scans annual maximum Ultrasound Scans The cost incurred when performed in a private office.	$50	$50	$50	$50
Magnetic Resonance Imaging annual maximum Magnetic Resonance Imaging Expenses incurred when required for diagnosis or treatment of an illness or injury, when prescribed or requested by attending Physician.	$500	$500	$500	$500
Audiologist	$500 annual maximum	$500 annual maximum	$500 annual maximum	$500 annual maximum
Laboratory Tests annual maximum Laboratory Tests Expenses for blood tests, urine tests and throat cultures required as a result of an accident or for the diagnosis or treatment of an illness.	$100 per category	$100 per category	$100 per category	$100 per category
Homecare and Nursing, Prosthetic Appliances and Durable Medical Equipment Homecare and Nursing, Prosthetic Appliances and Durable Medical Equipment Covers the services of a Registered Nurse, Registered Practical Nurse, Certified Home Support Worker, Occupational Therapist or Registered Dietitian; includes surgical bandages and dressings and the purchase or rental of medically necessary equipment such as crutches, non-electric wheelchairs and hospital beds, oxygen and other equipment recommended by your physician and approved by Manulife Financial. Also includes prosthetic appliances such as artificial limbs, eyes, splints, casts and breast prostheses following mastectomies. Payment will be coordinated where benefits are available through the Assistive Devices Program.	For each of Homecare and Nursing, Prosthetic Appliances and Durable Medical Equipment: Year 1: $1,000 Year 2: $1,300 Year 3: $1,500 Year 4: $2,000 Year 5+: $2,500 Custom-made Orthotics: $225 per year	For each of Homecare and Nursing, Prosthetic Appliances and Durable Medical Equipment: Year 1: $1,000 Year 2: $1,300 Year 3: $1,500 Year 4: $2,000 Year 5+: $2,500 Custom-made Orthotics: $225 per year	For each of Homecare and Nursing, Prosthetic Appliances and Durable Medical Equipment: Year 1: $1,000 Year 2: $1,300 Year 3: $1,500 Year 4: $2,000 Year 5+: $2,500 Custom-made Orthotics: $225 per year	For each of Homecare and Nursing, Prosthetic Appliances and Durable Medical Equipment: Year 1: $1,000 Year 2: $1,300 Year 3: $1,500 Year 4: $2,000 Year 5+: $2,500 Custom-made Orthotics: $225 per year
Hearing Aids Hearing Aids Covers the cost to purchase and/or repair up to the allowed maximum.	$300 per 4-year period	$300 per 4-year period	$300 per 4-year period	$300 per 4-year period
Ambulance Services Ambulance Services Covers trips to hospitals in a licensed ambulance. Covers charges up to the amount between what your provincial health plan covers and what is reasonable and customary.	Unlimited ground transport $4,000 maximum air ambulance	Unlimited ground transport $4,000 maximum air ambulance	Unlimited ground transport $4,000 maximum air ambulance	Unlimited ground transport $4,000 maximum air ambulance
Accidental Dental Accidental Dental Covers dental treatment required as a result of an accidental blow to the head or mouth. Treatment must be sought within the 90-day period following the accident.	$2,000 per year	$2,000 per year	$2,000 per year	$2,000 per year
Lifetime Maximum	$100,000	$100,000	$100,000	$100,000
	Information purposes only.

Download and send us the completed form
by fax at 1-888-725-5921,
by email info@acyva.com or by mail:
Acyva Conseillers en assurances, 4150 W. Ste-Catherine St.
Suite 490, Westmount (Québec) Canada H3Z 2W8

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