personal choice -152010

Thank you for your interest in an Alberta Blue Cross Individual Health Plan. As you complete your application, please remember to include the following: Complete banking information (including Branch Number, Financial

Institution Number and Account Number). Alberta Blue Cross will debit the initial two months’ payment, withdraw subsequent monthly payments and directly deposit claims payments to the account provided.

Your authorization signature on the application form for automatic payment withdrawal and direct deposit of claims payment.

The nine digit Personal Health Number located on the Alberta Personal Health Card for each individual listed on the application.

Your signature and the signature of Co-Applicant/Spouse on the Acknowledgement and Consent section of the application.

Current date on the Acknowledgement and Consent section of the application.

Please ensure you have spoken with one of our licensed representatives prior to submitting an application for coverage. If you have any questions regarding the attached information, I can be reached in Edmonton at 780-498-8525 or toll-free province-wide at 1-800-394-1965, extension 8525. We cannot review your eligibility for coverage until this application has been fully completed and returned to us. Your completed application can be faxed to 780-498-3529 (toll free at 1-877-498-3529), e-mailed to [email protected] or mailed to Alberta Blue Cross at theEdmonton address listed below. Sincerely, Shannon RyanIndividual Products Alberta Blue Cross 10009 108 Street Edmonton, AB T5J 3C5 780-498-8525

Edmonton Blue Cross Place 10009 108 Street NW T5J 3C5 780-498-8000

Calgary Main Floor 715 5 Avenue SW T2P 2X6 403- 234-9666

Grande Prairie Suite 108 10126 120 Avenue T8V 8H9 780-532-3505

Lethbridge 470 Chancery Court 220 4 Street S T1J 4J7 403-328-1785

Medicine Hat 203 Chinook Place 623-4 Street SE T1A 0L1 403-529-5553

Red Deer 152 Riverside Office Plaza 4919 59 Street T4N 6C9 403-343-7009

www.ab.bluecross.ca ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.

You insure your belongings against loss and damage, so why not protect your most valuable possession—your health?

Without an Alberta Blue Cross individual health plan, you could face substantial out-of-pocket costs for prescription drugs, dental, vision care, ambulance trips and much more. And without coverage, an unexpected illness, accident or medical condition could cost you thousands of dollars.

If you’re without employer-sponsored health benefits, Alberta Blue Cross has an individual health and dental plan to meet your needs...and your budget.

Practical benefits you’ll use every dayAlberta Blue Cross individual health plans provide practical benefits you will use on a regular basis, including prescription drugs, vision, dental care and more.

Family protection —for today and tomorrowIf you’re healthy right now and think you don’t need a plan, you’re taking an unnecessary risk. Qualify for a plan today and a future illness, accident, medical condition or health problem won’t leave you and your family in a financial bind.

Affordable ratesWith potentially sizeable tax savings, a plan from Alberta Blue Cross is a lot more affordable than you might think. If you are the sole shareholder and employee of a corporation, you may be able to claim your premiums as a business expense—which means a direct reduction in your taxable income. For other individuals, your premiums qualify as a medical expense and can be added to other medical expenses when calculating personal income tax credits.

Combine the tax savings with what you’ll save on out-of-pocket expenses each year, and you’ll be surprised how little an Alberta Blue Cross individual health plan actually costs.

Take hold of your healthy future

You must complete a medical questionnaire to determine eligibility for certain benefits as these plans are medically reviewed and do not cover pre-existing health conditions or medications.

All the advantages of a group benefit planWith Alberta Blue Cross individual health plans, you receive many of the same benefits as employees of large corporations: prescription drugs, ambulance services, dental and vision care, extended health benefits and much more. You can also enjoy the convenience of direct billing arrangements with pharmacies and most dental offices. And with payments through automatic monthly withdrawals, you can budget health costs to avoid surprises and support a healthy lifestyle.

Peace of mind from the name you know and trustAt Alberta Blue Cross, your health is our only business. We serve the health and dental needs of over 1.5 million Albertans. And as an Alberta-based, not-for-profit organization, we respond immediately to health policy changes that affect you—and deliver the value and affordability you deserve.

Individual Health Plans make good sense

Personal Choice • Plan AExtended Health CoverageAmbulance ServicesAccidental Dental Care: Up to a maximum of $1,500 per participant for the repair, extraction or replacement of natural teeth.Psychologist: Up to $60 per visit to a maximum of $120 per participant each benefit year.

Drug CoverageAll drug coverage paid according to the Personal Choice Drug Benefit List.

70% Reimbursement for eligible prescription drugs.Least Cost Alternative (LCA) Pricing.$10,000 maximum per participant each benefit year. (Fertility drugs, weight loss drugs, smoking cessation products and birth control implants are not covered.)

Dental CoverageAll dental services paid according to the Alberta Blue Cross Dental Schedule.

100% for standard check-ups and cleanings* and 80% for fillings, extractions, and root canals to a combined maximum of $600 per participant in each benefit year.(Three month waiting period from enrolment date.)

Accidental Death Benefit$10,000 in the event of an accidental death of a participant.Accidental Death Benefit underwritten by the Blue Cross Life Insurance Company of Canada.

Plan Maximum: Drug Coverage and Extended Health Coverage combined maximum of $15,000 per participant each benefit year and $250,000 lifetime.

Personal Choice • Plan BExtended Health CoverageAmbulance ServicesPreferred Hospital Accommodation: Semi-private and privaterooms. Up to $50 per day to a maximum of $1,000 per participant each benefit year.Physiotherapist/Chiropractor: Up to $25 per visit for services provided by a chiropractor or $30 per visit for services provided by a physiotherapist to a combined maximum of $300 per participant each benefit year.Home Nursing: Up to a maximum of $3,000 per participant each benefit year.Psychologist: Up to $60 per visit to a maximum of $600 per participant each benefit year.Podiatrist/Chiropodist: Up to $15 per visit to a maximum of $300 per participant each benefit year for services provided by a chiropodist or podiatrist.Accidental Dental Care: Up to a maximum of $2,000 per participant for the repair, extraction or replacement of natural teeth.Hearing Aids: Up to a maximum of $500 per participant in any four year period for the purchase or repair of hearing aids.Custom Made Foot Orthotics: 70% coverage up to a maximum of $200 per participant each benefit year.Custom Fitted Braces: 70% coverage up to a maximum of $750 per participant in any two year period.Blood Glucose Meter / Blood Pressure Monitor: Up to a combined maximum of $150 once in any five year period.Wheelchair: Wheelchair up to a maximum of $1,500 once in any three year period.Hospital Beds: Hospital beds lifetime maximum of $1,500 per participant.Medical Aids: Splints, trusses, crutches, casts, canes, cervicalcollars, walkers, and traction kits.CPAP Machines: Sleep Apnea appliances up to a combined maximum of $500 per participant once in any 5 year period.


70% Direct Bill for eligible prescription drugs.Least Cost Alternative (LCA) Pricing.$10,000 maximum per participant each benefit year. (Fertility drugs, weight loss drugs, smoking cessation products and birth control implants are not covered.)



50% extensive dental for periodontics and dentures in the second year to a combined basic and extensive maximum of $1,000 per participant in the second and each subsequent benefit year.(12 month waiting period from enrolment date.)

Vision Care CoverageCombined maximum of $150 per participant towards an eye examination (to a maximum of $50) and the purchase and repair of eyeglasses, contact lenses and intraocular lenses in any two year period.

Accidental Death Benefit$15,000 in the event of an accidental death of a participant. Accidental Death Benefit underwritten by the Blue Cross Life Insurance Company of Canada.


Now is the time to assess your health

coverage needs. Whether you’re self-

employed, working without group benefits

or an early retiree, Alberta Blue Cross

individual health plans are a smart choice

for you and your family.

Please review the plan choices and select

one today.

Personal Choice • Plan CExtended Health CoverageAmbulance ServicesPreferred Hospital Accommodation: Semi-private and privaterooms. Up to $50 per day to a maximum of $1,500 per participant each benefit year.Physiotherapist/Chiropractor: Up to $25 per visit for services provided by a chiropractor or $30 per visit for services provided by a physiotherapist to a combined maximum of $300 per participant each benefit year.Home Nursing: Up to a maximum of $5,000 per participant each benefit year.Psychologist: Up to $60 per visit to a maximum of $600 per participant each benefit year.Podiatrist/Chiropodist: Up to $15 per visit to a maximum of $300 per participant each benefit year for services provided by a chiropodist or podiatrist.Accidental Dental Care: Up to a maximum of $2,500 per participant for the repair, extraction or replacement of natural teeth.Hearing Aids: Up to a maximum of $750 per participant in any four year period for the purchase or repair of hearing aids.Auxiliary Care: Up to a maximum of $1,000 per participant each benefit year. Custom Made Foot Orthotics: 70% coverage up to a maximum of $200 per participant each benefit year.Custom Fitted Braces: 70% coverage up to a maximum of $750 per participant in any two year period.Blood Glucose Meter / Blood Pressure Monitor: Up to a combined maximum of $150 once in any five year period.Wheelchair: Wheelchair up to a maximum of $1,500 once in any three year period.Hospital Beds: Hospital beds lifetime maximum of $1,500 per participant.Medical Aids: Splints, trusses, crutches, casts, canes, cervical collars, walkers, and traction kits.CPAP Machines: Sleep Apnea appliances up to a combined maximum of $500 per participant once in any 5 year period.


80% Direct Bill for eligible prescription drugs.Least Cost Alternative (LCA) Pricing.$10,000 maximum per participant each benefit year.(Fertility drugs, weight loss drugs, smoking cessation products and birth control implants are not covered.)



50% extensive dental for periodontics and dentures in the second year to a combined basic and extensive maximum of $1,000 per participant in the second and each subsequent benefit year.(12 month waiting period from enrolment date.)

50% extensive dental for crowns, bridges and implants in the third year to a combined basic and extensive maximum of $1,000 per participant in the third and each subsequent benefit year.(24 month waiting period from enrolment date.)

50% for orthodontics in the third year to a lifetime maximum of $1,500 per participant.(24 month waiting period from enrolment date.)

Vision Care CoverageCombined maximum of $200 per participant towards an eye examination (to a maximum of $50) and the purchase and repair of eyeglasses, contact lenses and intraocular lenses in any two year period.

Accidental Death Benefit$20,000 in the event of an accidental death of a participant. Accidental Death Benefit underwritten by the Blue Cross Life Insurance Company of Canada.


Additional benefitsPlan portability optionIn the future, you may have an opportunity to acquire group benefits through an employer. But there’s no need to leave your Personal Choice individual health plan behind. You can maintain the option to resume your coverage sometime in the future, without a medical review. This guarantees you and your family will always have access to an Alberta Blue Cross individual health plan, regardless of medical conditions. Some restrictions will apply.

Travel Coverage DiscountA 10% discount on Alberta Blue Cross out-of-province emergency medical travel coverage is available to all Personal Choice participants.

Health & Wellness CompanionAll Alberta Blue Cross Personal Choice participants are eligible to access the Alberta Blue Cross Health & Wellness Companion, a set of online health risk assessment tools and health information resources designed to help you maintain your health. This user-friendly benefit is accessible through the Alberta Blue Cross Internet web site.

This brochure provides an overview of Personal Choice plans offered by Alberta Blue Cross. It is not a contract or complete listing of all benefits.

*A standard check-up and cleaning includes a new patient exam (code 01101, 01102, 01103 or 01201) or a recall exam, bitewing radiographs, one time unit of polishing, up to two time units of scaling or root planing, and fluoride.

Alberta Blue CrossIndividual Health Plans10009 - 108 StreetEdmonton, AB T5J 3C5

1-800-394-1965780-498-8008 in Edmonton403-294-4032 in Calgary

Claim and benefit inquiries:1-800-661-6995

1. Select the plan that suits your needs

2. Refer to the Rate Chart that accompanies this brochure

3. Complete all parts of the application form

• Be sure to sign and date the application

• Incomplete information will cause delays

4. Forward your fully completed application by e-mail, fax or mail

Your application will be medically reviewed and you will be notified whether you have been accepted or declined. If you are accepted, coverage will begin the first day of the month following the acceptance of your application. Dental coverage waiting periods apply.

Don’t delay—you never know when an illness or accident may occur.

If you have any questions, just call us!

There’s an Alberta Blue Cross representative ready to help you.

Enjoy the benefits of a Personal Choice individual health plan—apply today.

www.ab.bluecross.ca

® The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan. ABC 40320 (R12/2009)

It’s easy to apply

PERSONAL CHOICE PLAN APPLICATION

Please fill out the following Personal Choice Plan Application. This three page Application forms part of your Agreement for the Personal Choice Plan. This Application will not be considered for acceptance unless it is completed in ink and all questions are answered fully and completely. Please print.

The Personal Choice Plan Application contains three sections: Page 1 – General Information and Plan Selection Page 2 – Medical Information Page 3 – Monthly Payment / Direct Deposit of Claims Authorization and Acknowledgement / Consent

A. GENERAL INFORMATION: List all individuals covered under the Applicant’s Alberta Health Care Insurance Plan account,

indicating Dependent’s last name if different from Applicant.

Last Name First Name Middle Initial

Gender (M / F) Date of birth

9-digit Alberta Personal Health Number (PHN) Height Weight

Applicant yyyy / mm / dd

/ /

ft/in cm lbs kg

Co-Applicant/Spouse yyyy / mm / dd

/ /

ft/in cm lbs kg

Dependents yyyy / mm / dd

/ /

yyyy / mm / dd

/ /

yyyy / mm / dd

/ /

yyyy / mm / dd

/ /

yyyy / mm / dd

/ /

Address City Province Postal Code

Home phone number: Daytime phone number: Best time to call: E-mail address:

B. SELECT YOUR PERSONAL CHOICE PLAN: I/we are applying for coverage under Personal Choice Plans as described in the Personal Choice Individual Health Plan brochure enclosed with this Application:

Plan A Plan B Plan C If you require more detailed benefit information than the Personal Choice Individual Health Plan brochure or require the Personal Choice

Plan Standard Terms and Benefit Schedule, please contact an Alberta Blue Cross representative at 1-800-394-1965.

Previous health benefits information:

1. Have you terminated or will you be terminating from a group benefit plan within 30 days? No Yes 2. If yes: For Alberta Blue Cross plans, complete the following:

Name of employer: Group number: ID number: Termination date:

3. For other plans, attach a Group Conversion form. (This form must be completed by your group plan administrator.)

4. If you have the Non-Group plan (Group 1), would you like it cancelled if you are accepted on this plan? No Yes

C. MEDICAL INFORMATION: (All questions must be answered completely.) In order to be considered for Personal Choice Plan coverage, Alberta Blue Cross must have complete medical history of the Applicant, Co-Applicant and all Dependents to be covered. Any injury or sickness, the signs of which first appeared on or before the date of this Application must be fully disclosed in this Application. Alberta Blue Cross and Blue Cross Life Insurance Company of Canada reserve the right to reject coverage, or rate or exclude certain benefits for an Applicant, Co-Applicant or Dependent based on Alberta Blue Cross’s assessment of your/their medical history. Applicants/Co-Applicants and Dependents must cooperate fully with Alberta Blue Cross in verifying the information provided and understand that your failure to cooperate may lead to the Application being rejected or the Agreement being cancelled.

1. Applicant’s last visit to a medical doctor: a) Applicant’s first and last name: b) Name of physician, medical doctor or clinic last seen: c) Date of last visit (yyyy/mm/dd):

d) Reason for visit (If reason given as checkup, what problem/symptoms did you have?):

e) Indicate all findings, treatment or recommended follow-up (If none, state “none.”):

2. Co-Applicant’s/Spouse’s last visit to a medical doctor: a) Co-Applicant’s/Spouse’s first and last name:

b) Name of physician, medical doctor or clinic last seen: c) Date of last visit (yyyy/mm/dd):

d) Reason for visit (If reason given as checkup, what problem/symptoms did you have?):

e) Indicate all findings, treatment or recommended follow-up (If none, state “none.”):

3. Has any person listed in Section A taken or been prescribed any medication for any reason in the past 12 months?

No Yes - Please check one. If yes, provide details below (include pills, creams, drops, inhalers, patch, suppository, etc.).

Person’s Name Prescription name & strength Dose & frequency used Number of refills/year Reason for taking

4. Has any person listed in Section A ever consulted a physician or medical practitioner, been treated for, or had any

indication of: a) Alcohol or drug abuse No Yes b) Bone or joint disorder (ie. arthritis, low bone density, etc.) No Yes

c) Cancer, tumour or leukemia No Yes d) Chest pain, heart or circulatory abnormalities No Yes e) Diabetes or elevated blood sugars No Yes f) High blood pressure or elevated cholesterol No Yes g) Recurrent infections (ie. Herpes virus, UTIs, etc.) No Yes h) Skin disorder (ie. acne, eczema, etc.) No Yes i) Chronic headaches, migraine headaches, dizziness No Yes j) Neurological disorder (ie. seizures, stroke, paralysis, etc.) No Yes

k) Gastrointestinal, kidney or liver disorder (ie. ulcers, GERD, Colitis, Crohn’s, Hepatitis, etc.) No Yes

l) Psychological, mood, nervous, emotional or behavioural disorder No Yes (ie. depression, anxiety, bipolar, Attention Deficit Disorder, etc.)

m) Respiratory, lung disorder or allergies No Yes (ie. asthma, sleep apnea, COPD, etc.)

n) AIDS, positive HIV test or other immunological disorder No Yes o) Chiropractic services (specifically in the last 12 months) No Yes

p) Physiotherapy services (specifically in the last 12 months) No Yes

q) Psychological counselling (specifically in the last 12 months) No Yes

Use this section to provide details for all Yes answers to the above questions. (Use a separate page if more space is required.) Person’s name Illness, medical condition Type of treatment Date diagnosed Date last treated Current status

5. Does any person listed in Section A have any physical impairment, condition, disease or disorder not listed above or require a medical aid (ie. hearing aid, braces, wheelchair, CPAP, artificial eye, prosthesis, etc.)? No Yes If yes, provide details:

6. Does any person listed in Section A have any outstanding tests, investigations, referrals or recommended follow-ups? No Yes If yes, provide details:

Please use a separate page if more space is required for any of the above questions.

D. MONTHLY PAYMENT AND DIRECT DEPOSIT OF CLAIMS AUTHORIZATION: Complete the information below as it appears on your cheque OR enclose a blank cheque marked “VOID”. Your authorization signature must be provided below.

Cheque Number

(3 digits – not required) Branch (Transit) Number

(5 digits) Financial Institution

Number (3 digits) Account Number

(Maximum 12 digits)

I, the account holder, authorize Alberta Blue Cross to withdraw the initial two months’ payment, subsequent monthly payments and directly deposit claims payments to my account indicated above or on the enclosed cheque. I agree to the terms and conditions established by Alberta Blue Cross until such time as written notice to the contrary is given by me to Alberta Blue Cross. Print Name of Account Holder:

Authorization Signature:

By signing here, you are authorizing Alberta Blue Cross to withdraw the initial two months’ payment, subsequent monthly payments and directly deposit claims payments to the account provided. If you would like to have your claims deposited into a different account, please contact Alberta Blue Cross at 1-800-394-1965.

E. ACKNOWLEDGEMENT AND CONSENT: (Please read, date and sign below.)

Failure to complete this Application in its entirety will result in delays. Upon receipt of a completed Application with all the required information and verification of medical information, Alberta Blue Cross will provide a response to this Application for coverage within 30 days. Applicants/Co-Applicants and Dependents must cooperate fully with Alberta Blue Cross in verifying the information provided and understand that your failure to cooperate may lead to the Application being rejected or the Agreement being cancelled. If all the required information is not received within 60 days, the Application will be closed. a. Acceptance – Upon acceptance of this Application, Alberta Blue Cross will confirm

coverage through the issuance of identification cards with an effective date determined by Alberta Blue Cross. The Agreement will include: Personal Choice Plan Application, Personal Choice Plan Standard Terms and Benefit Schedule along with the following, if applicable: Exclusion Agreement, Rating Agreement and Conversion of Personal Choice Plan to Health Plus Plan. The Personal Choice Individual Health Plan brochure is for marketing purposes only and does not form part of the Agreement. Amendment(s) to the Personal Choice Standard Terms and Benefit Schedule will be based on Alberta Blue Cross’s assessment of all of the provided information. Alberta Blue Cross may amend the provisions of this Agreement at any time by providing 30 days written notice to the plan Member. If the plan Member is not satisfied with the Personal Choice Plan Terms and Benefit Schedule they may be returned to Alberta Blue Cross for termination within twenty (20) days of receipt and all payments will be refunded.

b. Rejection – In the event that this Application is rejected, Alberta Blue Cross will return all of the information provided to Alberta Blue Cross. All other information relating to this Application will be destroyed.

Use of your personal information I/we understand that the personal information provided herein as well as other personal information currently held or collected in the future by Alberta Blue Cross and/or Blue Cross

Life Insurance Company of Canada will only be collected, used, or disclosed to administer the terms of my/our Personal Choice Plan; verify my/our eligibility for coverage; verify, assess and pay claims; and develop and recommend suitable products and services to me/us. I/we acknowledge and agree that my/our or my dependents’ personal information may only be collected from and/or released to a third party (health care professional / practitioner / institution or insurer/agent of record) only when needed for a purpose stated above. I/we certify that the member is authorized by his/her spouse and/or other adult dependents to disclose and receive information about them that is used solely for these purposes. I/we understand that my/our personal information will be kept confidential and secure. Your acknowledgement and consent I/we understand that I/we may revoke my/our consent at any time, however, if consent is withheld or revoked, the coverage may be denied or rescinded. I/we understand why my/our personal information is needed and are aware of the risks and benefits of consenting or refusing to consent to its disclosure. I/we have read and understood this complete Application, including this Acknowledgement and Consent, and agree to all terms and conditions of the Agreement. I/we agree that this consent shall be effective from the date of the Application and shall remain in effect as long as the Agreement is in force, unless I revoke it in writing. I/we authorize the collection, use and disclosure of my/our personal information as described above. I/we hereby apply for the Health and Dental Coverage underwritten by Alberta Blue Cross. Head Office: 10009 108 St. NW, Edmonton, Alberta T5J 3C5. I/we hereby apply for the Accidental Death Insurance underwritten by Blue Cross Life Insurance Company of Canada. Corporate Office: 644 Main Street, P.O. Box 220, Moncton, New Brunswick E1C 8L3. A photographic copy of this authorization shall be as valid as the original. This consent complies with provincial and federal privacy legislation.

I/we have read and understood the entire Application and certify that all questions are answered fully and completely. I/we understand that facts known by myself/us or listed Dependents – but not stated on the Application – could result in the denial of coverage, denial of a claim, modifications of the rate or cancellation of the Agreement.

Date (yyyy/mm/dd): 20 ___ ___ / ___ ___ / ___ ___ Signature of Applicant: This consent will be valid from this date, will continue while this

Agreement is in force and will end when Agreement is cancelled.

Please print name here:

Signature of Co-Applicant/Spouse:

ABC 30629 R2010/11 Please print name here:

All three pages of this Application must be completed

AGENT’S USE ONLY AGENT’S NAME (Please print, if applicable) COMPANY NAME AGENT’S SIGNATURE

MAILING ADDRESS E-MAIL ADDRESS TELEPHONE NUMBER

Fill in your bank account number here

PERSONAL CHOICE RATES

RATE CHART (Monthly rates for each family member)

PLAN AGE TYPE 4 AND UNDER 5 - 20 * 21 - 34 35 - 44 45 - 54 55 - 64

PLAN A $ 11.00 $ 29.00 $ 46.00 $ 47.00 $ 55.00 $ 65.00

PLAN B $ 12.00 $ 31.00 $ 59.00 $ 63.00 $ 74.00 $ 85.00

PLAN C $ 14.00 $ 38.00 $ 71.00 $ 75.00 $ 97.00 $ 115.00

* If all applicants are under 21 years of age then one of the applicants must use the 21 - 34 rates listed above.

INSTRUCTIONS RATE CALCULATION All individuals covered under the Applicant's

Alberta Health Care Insurance Plan account must be on the same Personal Choice plan.

1. Select your plan type.

2. Using the Rate Chart above, insert the rate for each family member into the Rate Calculation amount column.

3. Add the rate(s) within the amount column to determine your Total Monthly Rate.

4. Multiply the total monthly rate by 2 to determine your initial 2 months’ payment.

PERSON COVERED AMOUNT

APPLICANT

SPOUSE +

DEPENDENTS +

+

+

+

+

+

+

+

MONTHLY RATE =

INITIAL 2 MONTHS’ PAYMENT

(Monthly rate x 2) =

These rates are subject to change without notice. Acceptance of the above noted rates does not constitute acceptance of the Agreement. Rates stated above may change pending medical underwriting.

® The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan. ABC 30895 R2010/11

Tax savings!Tax savings!Is your family’s health worth an

additional $50 a year?

If you can spare an additional $50 a year to put toward your family’s health, you can

potentially afford an Alberta Blue Cross individual health plan. That’s because if you’re

self-employed, your rates may be tax deductible.

Here’s an example...

®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan. ABC 40502_80742 (R01/2010)

Approximate cost per year, for a family of three

Alberta Blue Cross Individual Plan B rates . . . . . . . . . . . . . . . $1,704

Tax savings (at 32 per cent marginal tax rate) . . . . . . . . . . . . . . .- $545

Net plan cost (including tax savings) . . . . . . . . . . . . . . . . . . . . . . . . . .$1,159Remember, if your marginal tax rate is higher, you gain even greater tax savings.

Saved annual expenses (these are conservative estimates!)

•Dentalcheck-upsandcleanings (two adults and one child) $609

•Fillingsanddentalwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200

•Eyeexamandglasses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100

•Prescriptiondrugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200

Total expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$1,109

Net plan cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50Including tax savings and existing expenses

Now consider the “what-ifs” . . .such as a root canal or chipped tooth, an ambulance ride, a hospital stay, or an unexpected

medical condition, and you come out ahead .

Your plan could potentially pay for itself on everyday

costs alone.The above is an example only.

vision dental prescription drugs ambulance extended health benefits

Tax advantages!Tax advantages!Make coverage more affordable than ever . . .

There has never been a better time than right now for you and your family to enjoy the benefits of an individual health plan from Alberta Blue Cross.

That’s because with Canada’s taxation laws, Alberta Blue Cross health and dental plan rates may be tax-deductible for you. That could mean sizeable savings off the cost of coverage for you and your family.

Incorporated businesses . . .Owner-managers of incorporated businesses can claim their health and dental rates as a business expense. Rates paid would not be included as income, or considered a taxable benefit.

In fact, the rates you pay on behalf of employees are tax deductible. Meanwhile, your employees receive a benefit that’s considered non-taxable.

If you are self-employed . . .If self-employment is your primary source of income in the current year, you may be allowed to deduct the Alberta Blue Cross rates you pay as a business expense and receive a direct reduction in your taxable income.

That means an income tax savings of up to nearly 40 per cent of the rates you pay!

•Ifyouhavenopermanentfull-timeemployees(excludingfamilymembers), the annual deduction is limited to a maximum of $1,500 for each covered adult, and $750 for each covered child.

•Ifyouhaveoneormorepermanentfull-timeemployees(excludingfamily members), the annual deduction is limited in a different way. Your limit is based on the cost of equivalent coverage made available to the non-family member employee to whom you extend the least amount of coverage.

Individuals . . .Rates for health and dental coverage can be added to your other medical expenses when calculating tax credits. Medical expenses, including health and dental plan rates, may be claimed for any 12-month period ending in the taxation year, against either spouse’s income. To claim your rates, just include them in your total medical expenses on your tax return.

Call your accountant or Canada Revenue Agency for more details about how Alberta Blue Cross health and dental rates can save you tax dollars.

With these savings, can you afford

not to have an individual health plan?

vision dental prescription drugs ambulance extended health benefits

personal choice -152010

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