sfss health & dental plan

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2016–2017

SFSS HEALTH & DENTAL PLAN Your coverage includes:  Health  Vision

 Travel

 Dental

Save more money by visiting a Network member. Learn more: www.studentcare.ca Detach this section and use this card in conjunction with your student ID card to claim for prescription drugs covered by your Plan. Desjardins Financial Security Life Assurance Company

SIMON FRASER UNIVERSITY SFSS HEALTH & DENTAL PLAN Carrier

12

Group Number

Q1112

PAY-DIRECT CARD

Information for the pharmacist Please access the “ESC” system and enter the information on this card.

9-Digit Student ID Number

Student’s Name (Please PRINT)

USE YOUR PAY-DIRECT CARD FOR PRESCRIPTION DRUGS

Use of this card authorizes the following to exchange information for the purposes of underwriting, administration, audit, paying claims, and patient safety: Desjardins Financial Security, Studentcare, any person or organization who has relevant personal information about me, my spouse, or dependants including the pharmacy through which this card is used, health-care practitioners, institutions and insurers, and any person performing services for Desjardins Financial Security. If I am a spouse or a dependant, my claims information will be shared with the Plan member for the purposes of claims payment and benefits management. Detach this section and use this card in conjunction with your student ID card to claim for prescription drugs covered by your Plan.

Health & Dental Plan Office Maggie Benston Centre, Room 2240 Burnaby, BC Studentcare 1200 McGill College Avenue, Suite 2200 Montreal, QC H3B 4G7 Toll-free: 1 866 369-8795

Student’s Signature

If you’re covered, use this card in conjunction with your student ID card. Desjardins Financial Security Life Assurance Company

SFSS/FLIP/09-16

By presenting the Pay-Direct Card with your valid student ID card, you can fill your prescriptions at most Canadian pharmacies. The pharmacist will be able to process the claim immediately, so you won’t have to pay the full amount up front and wait to be reimbursed.