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 1-877-4983529), e-mailed to sryan@ab.bluecross.ca or mailed to Alberta Blue Cross at the Edmonton address listed below. Sincerely, Shannon Ryan Individual 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.

Take hold of your healthy future

Individual Health Plans make good sense
You insure your belongings against loss and damage, so why not protect your most valuable possessionyour 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 youre without employer-sponsored health benefits, Alberta Blue Cross has an individual health and dental plan to meet your needs...and your budget.

Practical benefits youll use every day

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

All the advantages of a group benefit plan

Family protectionfor today and tomorrow

If youre healthy right now and think you dont need a plan, youre taking an unnecessary risk. Qualify for a plan today and a future illness, accident, medical condition or health problem wont leave you and your family in a financial bind.

Affordable rates

With 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.

With 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 expensewhich 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 youll save on out-of-pocket expenses each year, and youll be surprised how little an Alberta Blue Cross individual health plan actually costs.

Peace of mind from the name you know and trust

At 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 youand deliver the value and affordability you deserve.

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.

Personal Choice Plan B

Extended Health Coverage
Ambulance Services Preferred Hospital Accommodation: Semi-private and private rooms. 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.

Now is the time to assess your health coverage needs. Whether youre selfemployed, 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.

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, 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.

Personal Choice Plan A

Extended Health Coverage
Ambulance Services Accidental 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 Coverage
All drug coverage paid according to the Personal Choice Drug Benefit List.

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.)

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

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

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.)

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.)

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

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.)

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.)

Vision Care Coverage

Combined 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

$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.

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. 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 C

Extended Health Coverage
Ambulance Services Preferred Hospital Accommodation: Semi-private and private rooms. 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.

Additional benefits
Plan portability option
In the future, you may have an opportunity to acquire group benefits through an employer. But theres 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 Discount

A 10% discount on Alberta Blue Cross out-ofprovince emergency medical travel coverage is available to all Personal Choice participants.

Health & Wellness Companion

All 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 userfriendly benefit is accessible through the Alberta Blue Cross Internet web site.

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

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.)

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

100% for standard check-ups and cleanings* and 90% 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.)

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.)

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.

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 Coverage

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

Its easy to apply

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. Dont delayyou never know when an illness or accident may occur. If you have any questions, just call us!

Theres an Alberta Blue Cross representative ready to help you. Enjoy the benefits of a Personal Choice individual health planapply today.
1-800-394-1965 780-498-8008 in Edmonton 403-294-4032 in Calgary Claim and benefit inquiries: 1-800-661-6995 Alberta Blue Cross Individual Health Plans 10009 - 108 Street Edmonton, AB T5J 3C5

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)

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 Applicants Alberta Health Care Insurance Plan account, indicating Dependents last name if different from Applicant. Last Name
Applicant

15

First Name

Middle Initial

Gender (M / F)

Date of birth
yyyy / mm / dd

9-digit Alberta Personal Health Number (PHN)

ft/in cm

Height

lbs kg

Weight

/
Co-Applicant/Spouse

/
ft/in cm lbs kg

yyyy / mm / dd

/
Dependents

/ / / / / /

yyyy / mm / dd

/ / / / /

yyyy / mm / dd yyyy / mm / dd

yyyy / mm / dd

yyyy / mm / dd

Address Home phone number: Daytime phone number:

City

Province E-mail address:

Postal Code

Best time to call:

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
Previous health benefits information:

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.

1. Have you terminated or will you be terminating from a group benefit plan within 30 days? 2. If yes: For Alberta Blue Cross plans, complete the following:
Name of employer: Group number: ID number:

No

Yes
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.)

15

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 Crosss 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. Applicants last visit to a medical doctor:

a) Applicants 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-Applicants/Spouses last visit to a medical doctor:

a) Co-Applicants/Spouses 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.).
Persons 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 b) Bone or joint disorder (ie. arthritis, low bone density, etc.) c) Cancer, tumour or leukemia d) Chest pain, heart or circulatory abnormalities e) Diabetes or elevated blood sugars f) High blood pressure or elevated cholesterol g) Recurrent infections (ie. Herpes virus, UTIs, etc.) h) Skin disorder (ie. acne, eczema, etc.) i) Chronic headaches, migraine headaches, dizziness j) Neurological disorder (ie. seizures, stroke, paralysis, etc.)

No No No No No No No No No No

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

k) Gastrointestinal, kidney or liver disorder

(ie. ulcers, GERD, Colitis, Crohns, Hepatitis, etc.)

No Yes No Yes No Yes No No No No Yes Yes Yes Yes

l) Psychological, mood, nervous, emotional or behavioural disorder m) Respiratory, lung disorder or allergies
(ie. asthma, sleep apnea, COPD, etc.)

(ie. depression, anxiety, bipolar, Attention Deficit Disorder, etc.)

n) AIDS, positive HIV test or other immunological disorder o) Chiropractic services (specifically in the last 12 months) p) Physiotherapy services (specifically in the last 12 months) q) Psychological counselling (specifically in the last 12 months)

Use this section to provide details for all Yes answers to the above questions. (Use a separate page if more space is required.)
Persons 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:

15

Complete the information below as it appears on your cheque OR enclose a blank cheque marked VOID. Your authorization signature must be provided below.

Fill in your bank account number here

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 Crosss 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):
This consent will be valid from this date, will continue while this Agreement is in force and will end when Agreement is cancelled.

20

___ ___

/ ___ ___ / ___ ___

Signature of Applicant:
Please print name here:

ABC 30629 R2010/11

Signature of Co-Applicant/Spouse:

Please print name here:

All three pages of this Application must be completed

AGENTS USE ONLY
AGENTS NAME (Please print, if applicable) COMPANY NAME AGENTS SIGNATURE

MAILING ADDRESS

E-MAIL ADDRESS

TELEPHONE NUMBER

PERSONAL CHOICE RATES RATE CHART (Monthly rates for each family member)
PLAN TYPE 4 AND UNDER 5 - 20 * AGE 21 - 34 35 - 44 45 - 54 55 - 64

PLAN A PLAN B PLAN C

$ 11.00 $ 12.00 $ 14.00

$ 29.00 $ 31.00 $ 38.00

$ 46.00 $ 59.00 $ 71.00

$ 47.00 $ 63.00 $ 75.00

$ 55.00 $ 74.00 $ 97.00

$ 65.00 $ 85.00 $ 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
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.

RATE CALCULATION
PERSON COVERED AMOUNT

APPLICANT SPOUSE DEPENDENTS + + + + + + + + + MONTHLY RATE = INITIAL 2 MONTHS = PAYMENT

(Monthly rate x 2)

0.00

0.00

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!
Approximate cost per year, for a family of three Alberta Blue Cross Individual Plan B rates Tax savings (at 32 per cent marginal tax rate)
............... . . . . . . . . . . . . . . .-

Is your familys health worth an additional $50 a year?

If you can spare an additional $50 a year to put toward your familys health, you can potentially afford an Alberta Blue Cross individual health plan.Thats because if youre self-employed, your rates may be tax deductible. Heres an example...

$1,704 $545

Net plan cost (including tax savings)

. . . . . . . . . . . . . . . . . . . . . . . . . . $1,159

Remember, if your marginal tax rate is higher, you gain even greater tax savings.

Saved annual expenses (these are conservative estimates!)

Dental check-ups and cleanings (two adults and one child) $609 Fillings and dental work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200 Eye exam and glasses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$1,109 ...............................................
The above is an example only.

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 .

Total expenses

Net plan cost

Including tax savings and existing expenses

$50

Your plan could potentially pay for itself on everyday costs alone.

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)

vision

dental

prescription drugs

ambulance

extended health benefits

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. Thats because with Canadas 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 thats 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! If you have no permanent full-time employees (excluding family members), the annual deduction is limited to a maximum of $1,500 for each covered adult, and $750 for each covered child. If you have one or more permanent full-time employees (excluding family 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.

With these savings, can you afford not to have an individual health plan?

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 spouses 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.

vision

dental

prescription drugs

ambulance

extended health benefits