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All this can add up to thousands of dollars out of your pocket. Depending on the plan you select, PlanDirect may cover these and other day-to-day expenses like eye examinations, eyeglasses and contact lenses, routine and major dental services, prescription medications and hearing aids. Unlike some individual medical insurance programs, PlanDirect: provides coverage for the treatment of pre-existing health conditions on approved applications does not require an overall lifetime maximum or any waiting periods is portable from province to province as long as you continue to qualify for provincial health insurance offers guaranteed acceptance for individuals coming from previous similar coverage within the last 60 days.*
With our plan selection, convenience and value, all you need to do is decide on the plan thats right for you.
* Please refer to the Rates booklet for details on our Guaranteed Acceptance program.
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Table of contents
PlanDirect coverage overview.................................................................................. 4 Eligibility and cost..................................................................................................... 6 Detailed information Plans................................................................................... 9 Healthcare services and supplies................................................................ 9 Dentalcare services and supplies.............................................................. 13 General limitations and exceptions.......................................................... 15 Specific limitations and exceptions........................................................... 16
PlanDirect optional coverage................................................................................. 17 Emergency Travel Medical Benefit............................................................ 17 Accidental Death, Dismemberment and Specific Loss Benefit.............. 23 Hospital Cash Benefit................................................................................. 25 Major Dental Services and Supplies Benefit............................................. 26 Enhanced Prescription Drug Benefit........................................................ 27
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Plan Designs
Value covers your essential healthcare needs, excluding prescription drugs. Basic covers your basic healthcare needs, plus prescription drugs. Advantage offers extended healthcare, including dental coverage, excluding prescription drugs. Comprehensive offers a wide range of benefits, including dental coverage and prescription drugs our most popular plan. Premier offers higher coverage levels and major dental coverage to people who had similar previous coverage.
Optional benefits
Emergency Travel Medical helps protect you against potentially high medical care costs incurred while travelling outside of Canada. Accidental Death, Dismemberment and Specific Loss provides you with added financial security if you or your dependants are faced with death or injury due to an accident. Hospital Cash offsets costs associated with an extended hospital stay. Major Dental Services and Supplies covers you for additional major dental services beyond the routine dental services provided by Advantage or Comprehensive Plan coverage. Enhanced Prescription Drug Benefit covers you for large, unexpected prescription drug expenses in addition to any drug coverage provided under your chosen PlanDirect plan.
Limitations may apply to optional coverage, depending on the plan design chosen. Please see the Optional Coverage section of this brochure for important definitions, limitations and exceptions.
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PLANS
PLANS
BENEFIT DETAILS
HOSPITAL ACCOMMODATION
HEALTH NO DRUGS 100% to $225 per day for a maximum of 90 days per calendar year for a semiprivate room No coverage
PRESCRIPTION DRUGS*
*See Notice to Quebec Residents on page 30 AMBULANCE SERVICES IN-HOME NURSING CARE Air & ground covered at 100% 90% up to $3,500 per person every 36 months
MEDICAL SUPPLIES, AIDS AND APPLIANCES DENTAL ACCIDENT CARE PARAMEDICAL SERVICES
90% up to maximums in policy Covered at 90% 90% up to maximums in policy One eye exam to a maximum of $50 every 24 months
90% up to maximums in policy Covered at 90% 90% up to maximums in policy One eye exam to a maximum of $50 every 24 months
VISIONCARE
Preferred Vision Services (PVS) discount on prescription eyewear and hearing aids at participating outlets. Great-West Lifes Health & Wellness Site comprehensive health information and interactive health-related tools, available online 24 hours a day, seven days a week. Health Information Service reliable information and reassurance with one phone call. Family Support Service links individuals to a network of qualified healthcare and homecare professionals. Nutrition Support Service expert advice that offers a proactive, self-care approach to wellness. Note: The above information is a summary only. Please see pages 9-16 for detailed coverage information. PLANDIRECT 4
ADVANTAGE PLAN HEALTH & DENTAL NO DRUGS 100% to $225 per day for a maximum of 90 days per calendar year for a semiprivate room No coverage
COMPREHENSIVE PLAN HEALTH & DENTAL WITH DRUGS 100% to $225 per day for a maximum of 90 days per calendar year for a semiprivate room Without drug card 100% to a maximum of $1,500 per person each calendar year or With drug card 85% to a maximum of $1,500 per person each calendar year Air & ground covered at 100% 100% up to $3,500 per person every 36 months
PREMIER PLAN HEALTH & DENTAL WITH DRUGS 100% to $250 per day with unlimited number of days for a private room 90% to a maximum of $2,000 per person each calendar year; includes drug card
Air & ground covered at 100% 100% up to $3,500 per person every 36 months
Air & ground covered at 100% 90% up to $1,500 each year including home health care aid 90% up to maximums in policy Covered at 90% 90% up to maximums in policy 90% up to $275 per person every 24 months One eye exam every 24 months 90% up to $800 per person every 5 years 85% unlimited maximum 50% up to $1,000 per person each calendar year for dentures, bridgework, crowns, posts, onlays & inlays $50,000 per person each calendar year
100% up to maximums in policy Covered at 100% 100% up to maximums in policy 100% up to $200 per person every 24 months One eye exam every 24 months 100% up to $500 per person every 5 years 80% up to $1,000 per person each calendar year No coverage (optional Major Dental Services and Supplies Benefit available) $40,000 per person each calendar year
100% up to maximums in policy Covered at 100% 100% up to maximums in policy 100% up to $200 per person every 24 months One eye exam every 24 months 100% up to $500 per person every 5 years 80% up to $1,000 per person each calendar year No coverage (optional Major Dental Services and Supplies Benefit available) $50,000 per person each calendar year
Optional Coverage
Emergency Travel Medical Benefit provides 30 consecutive day multi-trip coverage for under age 65, or 15 consecutive day multi-trip coverage for age 65-70 Accidental Death, Dismemberment and Specific Loss Benefit available in units of $25,000, up to 10 units Hospital Cash Benefit $50 per day beginning on the fourth day of hospitalization Major Dental Services and Supplies Benefit 50% up to $750 annually Enhanced Prescription Drug Benefit up to $250,000 annually per person Please see pages 17-27 for more details on the optional benefits you can add to enhance your PlanDirect plan coverage.
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PLANS
Eligibility
Youre eligible to apply for coverage under a PlanDirect plan if you are: a Canadian resident covered by your provincial healthcare plan between ages 50 and 70 if you have not had any supplementary health insurance coverage in the past 60 days between ages 50 and 75 if you have had supplementary health insurance coverage in the past 60 days.
Please note: The Premier plan is only available if you had similar coverage within the last 60 days, including major restorative dentalcare benefits.
In order to qualify any dependants for coverage: your spouse must be married to you, or living common law with you your children must be either under the age of 21, or under the age of 25 if theyre full-time students.
Optional coverage Youre eligible to apply for Accidental Death, Dismemberment and Specific Loss or Emergency Travel Medical optional coverage at any time. You can only apply for Hospital Cash, Enhanced Prescription Drug or Major Dental Services and Supplies Benefit options with your initial application for PlanDirect coverage. You may not add these coverages after the policy is in force. Your spouse and children must be covered under your PlanDirect plan to be eligible for any optional coverages.
Cost
The rates you pay for your PlanDirect plan are based on a number of factors, including: your province or territory of residence your age the plan you select the type of coverage you require (single, couple or family) the optional benefits you choose whether you have had similar prior coverage within the last 60 days the rate category you qualify for (see next page)
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Applicants with prior coverage The following three rate categories are available to you if you are age 50 to 75 and have had coverage similar to the PlanDirect coverage you are applying for within the last 60 days. Preferred Plus rates Please use our Preferred Plus rates if you have had similar coverage within the last 60 days, and can answer No to the two medical questions on the medical and lifestyle questionnaire on the application form. Preferred rates Please use our Preferred rates if you have had similar coverage within the last 60 days, and cannot answer No to the two medical questions on the medical and lifestyle questionnaire on the application form. Upon review of your PlanDirect application, if we determine that you do not qualify for Preferred rates, you will still qualify for coverage on a Guaranteed Acceptance rate basis. Guaranteed Acceptance rates Please use our Guaranteed Acceptance rates only if you are age 50 to 75, you have had similar coverage within the last 60 days, and you choose not to complete the two medical questions on the Medical and Lifestyle Questionnaire on the application form.* The Enhanced Prescription Drug Benefit is not available if you are applying for Guaranteed Acceptance rates.
* We recommend all applicants complete the Medical and Lifestyle Questionnaire as you may qualify for Preferred or Preferred Plus rates.
Applicants without prior coverage The following rate category is available to you if you are age 50 to 70 and have not had coverage similar to the PlanDirect coverage you are applying for within the last 60 days. Standard rates Please use our Standard rates if you have not had similar coverage within the last 60 days. You must complete the two medical questions on the medical and lifestyle questionnaire on the application form. Great-West reviews information required on the medical and lifestyle questionnaire, which forms part of the application for underwriting purposes. Based on your or a family members medical history, we may decline coverage, or adjust the premium charged for coverage.
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Healthcare services and supplies.......................................................................... 9 Dentalcare services and supplies........................................................................ 13 General limitations and exceptions.................................................................... 15 Specific limitations and exceptions.................................................................... 16
Nursing home care all plans cover: Accommodation in a nursing home, if accommodation starts while insured under the PlanDirect policy and is for acute, convalescent, chronic or palliative care. Coverage is for up to $50 per day, for 30 days per condition, per lifetime of the condition. Nursing home care must be approved by Great-West prior to commencement of care. Ambulance services all plans cover: Ambulance service including air ambulance, if provided by a licensed ambulance company for transportation to the nearest centre where essential treatment is available.
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Paramedical services All plans cover out-of-hospital treatment, after provincial benefits have been paid, for reasonable and customary charges for each of the following practitioners: licensed chiropractor for muscle and bone disorders; licensed osteopath; licensed naturopath; and licensed podiatrist for foot disorders; to a maximum for each of these practitioners of: $250 per insured person per calendar year (Value, Basic, Advantage and Comprehensive Plans); $365 per insured person per calendar year (Premier Plan); licensed physiotherapist for movement disorders to: $250 per insured person per calendar year (Value, Basic, Advantage and Comprehensive Plans); $425 per insured person per calendar year (Premier Plan); registered psychologist and social worker combined, to: $320 per insured person per calendar year (Value, Basic, Advantage and Comprehensive Plans); $370 per insured person per calendar year (Premier Plan); qualified speech therapist for speech impairments to: $270 per insured person per calendar year (Value, Basic, Advantage and Comprehensive Plans); $365 per insured person per calendar year (Premier Plan); qualified massage therapist to: $250 per insured person per calendar year (Advantage and Comprehensive Plans) $365 per insured person per calendar year (Premier Plan)
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*Note: The Value and Basic plans cover Dental Accident Treatment under Healthcare services and supplies, but they do not cover Dentalcare services and supplies.
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PlanDirect offers five options for individuals and families looking for additional protection against medical and dental expenses not covered under your provincial health plan. Emergency Travel Medical Benefit............................................................ 17 Accidental Death, Dismemberment and Specific Loss Benefit.............. 23 Hospital Cash Benefit................................................................................. 25 Major Dental Services and Supplies Benefit.............................................26 Enhanced Prescription Drug Benefit.........................................................27
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OPTIONAL COVERAGE
OPTIONAL COVERAGE
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Hospital services hospital in-patient services and supplies, including room and board and general nursing care while confined to a hospital semi-private room, ward, coronary care unit or intensive care unit for acute care; surgery; and hospital outpatient services and supplies. Physician services the services of a licensed physician. Emergency dental treatment benefits payable for emergency dental treatment provided for treatment to a sound natural tooth, required as a result of a blow from an external force, are limited to $1,000 per covered trip, and for a reason other than a blow from an external force, are limited to $200 per covered trip. Private duty nursing services a professional nurse, who is not a member of the insureds family, when provided during hospital confinement for emergency medical treatment, and when ordered by a physician. Miscellaneous services and supplies The following miscellaneous services and supplies are covered when provided on an in-patient or outpatient basis: anesthesia and its administration; diagnostic x-ray and laboratory examination; whole blood, blood plasma and blood products; oxygen and its administration; casts, dressings, crutches, canes, slings and splints; prescription drugs requiring a prescription by law; and rental of medical appliances, a hospital-type bed, wheelchair, crutches, braces, etc. (not to exceed the cost of purchase). Emergency medical assistance services Where Great-West has given its prior approval, Great-West will pay for, or reimburse expenses for, the following emergency medical assistance services resulting from a medical emergency, where arranged by the assistance centre. Medical evacuation and repatriation transportation to the nearest hospital where treatment is available or to a hospital in Canada. coverage for a medical attendant is also included, if required. Great-West reserves the right to transfer the insured to another hospital or return the insured to his or her home province or territory. Great-West will be absolved of any further liability for that medical emergency if the transfer request is refused.
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OPTIONAL COVERAGE
OPTIONAL COVERAGE
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Trip cancellation If, prior to a scheduled departure, an insured is required to cancel a trip due to: the death of an insured or an extended family member occurring within 22 days of the scheduled departure date; the injury or sickness, which did not result from a pre-existing condition, of an insured that caused the insured to be unable to start the trip. The attending physician must substantiate in writing that prior to the scheduled departure date, he or she advised the insured to cancel the trip or that the injury or sickness made it impossible for the insured to start the trip; the injury or sickness, which did not result from a pre-existing condition, of an extended family member which required immediate hospitalization with an expected stay of at least three days; or the enforceable call of an insured to jury duty or sudden and unexpected subpoena to act as a witness in a court of law during the trip, Great-West will reimburse the cost of pre-paid travel expenses which are not refundable or recoverable from any other source (limited to $2,500 per insured or $5,000 for all insureds per covered trip). For a benefit to become payable under the Trip Cancellation provision, Great-West must be notified within seven days of any cancellation in travel arrangements and Great-West must receive satisfactory proof of the reason for cancellation within seven days thereafter. Trip interruption if an insured has to end a covered trip and return to his or her home province or territory because the insured experienced a medical emergency, the cost of any non-refundable prepaid travel for the insured and for each insured travelling with the insured who has to return home (limited to $2,500 per insured or $5,000 for all insureds per covered trip). if the insured does not return home and opts to continue travelling after the medical emergency has ended, the additional cost of travel for the insured and for each insured person travelling with the insured. If required, Great-West will reimburse the additional cost for hotel accommodation and meals incurred by an insured travelling with the insured on account of the interruption. Benefits payable under the Trip Interruption provision are limited to $2,500 per insured or $5,000 for all insureds per covered trip. Unexpected return if an insured must return to his or her home province or territory because an extended family member who is not on the covered trip with the insured is suffering from an unforeseeable sickness or injury requiring intensive care treatment or has died, Great-West will reimburse the cost of any non-refundable prepaid travel express for each insured who is on the covered trip. Great-West will pay any extra cost for a one-way economy flight home (limited to $5,000 per insured per covered trip). Vehicle return if, for medical reasons, an insured or any accompanying person is unable to drive an automobile owned or leased by the insured to his or her home or to the place to which the automobile must be returned, the cost of returning the automobile (limited to $2,000 per covered trip). Benefits payable under this option will be reduced by 20 per cent, up to a maximum of $10,000, if in the event of a medical emergency, the assistance centre is not notified as required. This reduction in benefits payable does not apply if the total expenses incurred for medical services and supplies do not exceed $500.
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OPTIONAL COVERAGE
OPTIONAL COVERAGE
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Amount payable the full insured amount the full insured amount of the full insured amount of the full insured amount
Loss after termination of insurance Accidental death, dismemberment and specific loss benefits are payable for covered losses suffered after termination of this option, as long as the injury was sustained while this option was in force.
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OPTIONAL COVERAGE
OPTIONAL COVERAGE
$100,000
If you select an insured amount of $100,000 as shown in the example, and you have an accident that results in the loss of four fingers on one of your hands, the benefit amount payable would be of $100,000 or $25,000. The monthly cost per $25,000 unit is $2.75 for a single person; $4.00 for a couple; and $4.50 for a family. For example, if you purchase four units with family coverage, your cost would be four times $4.50 or $18.00 per month. Termination age This coverage is only available prior to age 71.
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OPTIONAL COVERAGE
OPTIONAL COVERAGE
The Major Dental Services and Supplies Benefit option is only available with your initial PlanDirect purchase. It may not be added later. Termination age The Major Dental Services and Supplies Benefit option can remain in effect as long as your PlanDirect policy remains in force.
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OPTIONAL COVERAGE
ADDITIONAL INFORMATION
FEATURES
The following additional services are available to you with your PlanDirect plan. However, these services are not part of the PlanDirect policy and are not underwritten by The Great-West Life Assurance Company. PVS Gives you and your dependants a discount on a wide selection of quality eyewear, lens extras and hearing aids purchased from a registered PVS network optician or optometrist. The discount applies to frames, prescription lenses, contact lenses and lens extras, such as scratch guard, tints, etc. PVS entitles you to a discount on laser eye surgery obtained through an organization that is part of the PVS network. PVS also entitles you to a discount on hearing aids (batteries, tubing, ear molds, etc.) when you purchase these items through a PVS network provider. Great-West Lifes Health & Wellness Site provides current, reliable health information you and your family can use, any time, to: Explore in-depth information on diseases, conditions, drugs and treatment options Read regularly updated health and wellness articles Learn how lifestyle influences health through the interactive Personal Health Risk Assessment and other health tools and quizzes Create a customized action plan to help make improvements to your lifestyle. Confidential services for you and your immediate family: Health Information Service Need answers to simple health questions, or worry that symptoms may point to something more serious? This service can help. You get information and reassurance with one phone call 24 hours a day, seven days a week. A registered nurse provides personalized telephone assistance. Family Support Service Links you to a network of qualified, on-call healthcare and home care professionals. Whether you are looking for a solution to a home care emergency or planning longterm care, you get the guidance you need. This is a referral service only; it does not cover the fees for professional and support services. Nutrition Support Service Offers a proactive, self-care approach to wellness. Helps you make positive changes to your diet by examining the underlying issues associated with weight loss/ gain, eating routines and lifestyle changes. Solutions include a self-directed package of useful tips, information and resources as well as professional consultation with a registered dietician in more complex situations. Health Information Service, Family Support Service, and Nutrition Support Service are offered by PDAdmin Group through Shepellfgi consultants.
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This section includes important information to help you apply for your PlanDirect plan.
To apply for PlanDirect, just fill out the application form in this package, and mail it to us with: a personalized, blank cheque marked VOID to establish pre-authorized payments; and a cheque for your first two months premium. If youre applying for Preferred, Preferred Plus, or Guaranteed Acceptance rates, please send a letter from your employer or a copy of your insurance billing, indicating your type of coverage Health, or Health and Dental and the expiry date of your policy. If youre applying for the Premier plan, your previous plan must have provided coverage for major restorative dental treatment. Your coverage begins on the first day of the month following the date that your application is approved. If you or your spouse, or any dependants, are confined to a hospital on the date that coverage would have otherwise started, it will begin on the date of release from the hospital. Changing your coverage Its important to choose your plan carefully. You may decrease your coverage after you have been insured at the higher level for one year. To move to a higher level of coverage you must again complete the Medical and Lifestyle Questionnaire and qualify for coverage. The Premier plan (for eligible applicants), the Hospital Cash Benefit option, the Enhanced Prescription Drug Benefit option and the Major Dental Services and Supplies Benefit option are only available when you first purchase your PlanDirect policy. Direct Deposit When you apply, you can choose to have your PlanDirect claims payments automatically deposited to your account with Direct Deposit from Great-West. With Direct Deposit, there are no delays receiving your cheques due to mail disruptions, no chance your cheques will be lost or stolen, and no need to deposit your cheques in person.
Making a claim
When youre enrolled, well send you a supply of claim forms. When you need to make a claim, simply fill out a claim form and send it, along with your original health and dental receipts, to Great-Wests Individual Health Unit at the address shown on the form. Forms are also available online through the Client Services section of the Great-West website at www.greatwestlife.com. Great-West will mail your claim cheque, together with a complete explanation of your benefits, directly to your home address. If you have a drug card under the Basic with Drug Card, Comprehensive with Drug Card or Premier plans, your Pay-Direct Drug Card will pay your eligible prescription drug expenses on the spot, to the amount covered by your plan. The Drug Card cannot be used for expenses under the Enhanced Prescription Drug Benefit.
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ADDITIONAL INFORMATION
ADDITIONAL INFORMATION
This brochure is intended only as a summary of the coverage provided. The policy contains important definitions, limitations and exceptions. You will receive the policy shortly after you have applied and been approved for coverage. We recommend you read the policy carefully when you receive it.
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The insurance coverage from my employer will end in three months. Can I enroll with PlanDirect after that? Yes, and if you apply within 60 days of when your coverage ends, you automatically qualify for coverage at our guaranteed acceptance rates and may even be eligible for our Preferred or Preferred Plus Rates, depending on your medical history. We suggest that you apply early in order to have uninterrupted coverage. Does PlanDirect cover me while Im travelling? While travelling within Canada, you will be covered by your PlanDirect policy to the same extent as you would be covered while in your own home province. For travel outside Canada, you must buy extra emergency hospital and medical travel insurance. However, your PlanDirect dental, drug, and paramedical coverage, if applicable, applies outside Canada as well. For more information on our optional Emergency Travel Medical Benefit, see page 17. I have a medical condition which has been controlled for years by medication. Can I still get coverage with PlanDirect? Information provided in the Medical and Lifestyle Questionnaire included with your application is reviewed by Great-West for underwriting purposes. While some applicants are declined based on the medical assessment, many people who join PlanDirect do have some kind of medical condition. You may also qualify for our Guaranteed Acceptance Rates without medical evidence, if you had similar previous coverage under a group health and dental plan in the last 60 days. Im over age 65. If I buy a plan that includes drug coverage, will it pay for the cost of prescriptions not covered under my provincial health plan? Yes. PlanDirect pays for eligible prescription drugs, as well as government plan deductibles and co-payments, so you are not out-of-pocket for these expenses. Are my premiums tax-deductible? Your health and dental plan premiums are considered a medical expense, and therefore, can be used to calculate your medical expense tax credit when completing your Federal Income Tax return.
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ADDITIONAL INFORMATION
ADDITIONAL INFORMATION
PDAdmin Group 200 -211 Consumers Road Willowdale ON M2J 4G8 Canada Phone (Toronto area): 416-490-0072 Toll-free anywhere in Canada: 1-800-565-4066 Fax: 416-490-6640 Email: plandirect@pdadmin.com Website: www.plandirect.com
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PlanDirect is administered by PDAdmin Group. PlanDirect policyowners are insured by The Great-West Life Assurance Company. Great-West Life and the key design are trademarks of The Great-West Life Assurance Company. PlanDirect and PDAdmin Group are trademarks of PlanDirect Insurance Services Inc., used under license by The Great-West Life Assurance Company.
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