Claim Forms

To make a claim for emergency medical expenses incurred while travelling out-of-province or out-of-country, complete the required form and return it, along with original receipts, to Allianz Global Assistance.

Note that Emergency Travel coverage is only included in the Total Health and Ultimate Health options for Extended Health Care coverage. If you chose Health Wise or Health Wise Plus, you are not covered for Emergency Travel.

To Make a Claim:

• Declaration of Insurability
• Allianz Emergency Medical Expense Claim Form
• Allianz Emergency Medical Expense Claim Form - French
• ARTA Traveller's Emergency Checklist

Other Travel Forms:

• Early Refill Request Form
• Change Application Form for Travel Plans

To make a claim for expenses covered under your Dental Care option, you and your dentist must complete the required form. You must then return it to the ARTA Retiree Benefits Plan administrator: Alberta School Employee Benefit Plan (ASEBP).

Note that a claim must be received before the end of the calendar year following the year during which you incurred the expense. Otherwise, it may not be paid.

To Make a Claim:

• Dental Care Claim Form
• Dental Care Claim Form - French

To make a claim for expenses covered under Total Health or Ultimate Health Trip Interruption / Cancellation Insurance, complete the required form and return it, along with original receipts, to Allianz Global Assistance.

To Make a Claim:

• Allianz Trip Cancellation/Interruption/Delay for Members Covered by Total Health or Ultimate Health
• Allianz Trip Cancellation/Interruption/Delay for Members Covered by Total Health or Ultimate Health - French

The ARTA Retiree Benefits Plan has a different authorization process for specialty drugs used to treat the following seven health conditions:

1. Ankylosing spondylitis
2. Chronic hepatitis C
3. Crohn’s disease/colitis
4. Multiple sclerosis
5. Psoriasis
6. Psoriatic arthritis
7. Rheumatoid arthritis

This process ensures physicians escalate therapies for these seven health conditions in a safe, gradual, and cost-effective way.

New Prescriptions

If you have a new prescription for a drug used to treat one of the health conditions above, and the Drug Enquiry Tool on the ARTA Member Health Care Account indicates it requires enhanced special authorization to be eligible for coverage, please follow the steps outlined below:

1. Discuss treatment options with your specialist.
2. Download the form that applies to your condition.
3. Complete and sign the patient section of the form (Part 1).
4. Provide the form to your specialist. They will complete their section of the form and submit to us.
5. We will advise you and your specialist, by letter, whether or not the drug will be covered.

Here’s some important information for you to know:

• Doctors or support groups may provide you complimentary doses of a specialty drug to take before you know if your coverage will be approved. Be advised that simply taking the drug is not a guarantee of coverage approval and that some specialty drugs are not easy to stop taking. So, if you start a course of treatment before receiving enhanced special authorization approval from us, there is a chance that coverage will not be approved and you will be responsible for the cost.
• If the drug you’ve been prescribed says it requires enhanced special authorization on the Drug Enquiry Tool on the ARTA Members Health Care Account but you’re not taking it for one of the five conditions listed above, you are not required to apply for enhanced special authorization. Your doctor will manage this process for you.

Renewing your Enhanced Special Authorization

You’ll have to renew your application for enhanced special authorization approval annually. Please follow the steps below to renew:

1. You’ll receive a letter from us 70 days prior to your approval ending letting you know it’s time to renew. When this happens, download the form that applies to your condition.
2. Complete and sign the patient section of the form (Part 1, sections A & B only).
3. Provide the form to your specialist. They will complete the form (Part 2, sections A & F only) and submit to us.
4. We will advise you and your specialist, by mail, whether or not the renewal is approved and the drug will continue to be covered.

Here’s some important information for you to know:

• If you haven’t taken the drug for more than 120 days (e.g. surgery or pregnancy prevented you from taking it or another benefit plan paid the claim), your specialist will need to explain the reason on their portion of the form.
• Chronic hepatitis C is not eligible for renewal as it is a one-time treatment.

To Make a Claim:

• Ankylosing Spondylitis - Enhanced Special Authorization form
• Chronic Hepatitis C - Enhanced Special Authorization form
• Crohn’s and Colitis - Enhanced Special Authorization form
• Multiple Sclerosis - Enhanced Special Authorization form
• Psoriasis - Enhanced Special Authorization form
• Psoriatic Arthritis - Enhanced Special Authorization form
• Rheumatoid Arthritis - Enhanced Special Authorization form