Update: Improvements and changes to the Public Service Health Care Plan­­­

As previously announced, effective July 1, 2023, changes will come into effect for all Public Service Heath Care Plan (PSHCP) members. The PSHCP is currently administered by Sun Life Financial. Following a competitive procurement process, which was unrelated to the new PSHCP changes, Canada Life Assurance Company will begin processing PSHCP claims as of July 1, 2023, which aligns with the effective date of the Plan changes below.

The PSHCP is negotiated at the PSHCP Partners Committee, comprised of Employer, Bargaining Agent and pensioner representatives. Improvements that modernize the PSHCP were the result of successful negotiations amongst all parties and responds to the needs of a diverse Canadian public sector workforce, its retirees and dependants, while respecting the publicly funded nature of the benefits members receive.

Further details have now been included to explain how improvements and changes will be administered as of July 1, 2023.

For all services and products where the maximum reimbursement amount will increase, the increase will come into effect on July 1, 2023. This means that the increased reimbursement will only apply to items or services incurred on or after July 1, 2023. 

For example, effective July 1, 2023, the benefit for massage therapy services increases from $300 to $500 annually. If a plan member submitted claims for $300 in massage therapy services incurred before July 1, 2023, they will be eligible to submit claims for another $200 after July 1, 2023, for services incurred after that date.

Additional information and examples are included in the ‘Details’ column in the table below.

Contents

PSHCP Improvements
Benefit Coverage reimbursed at 80% Details
Medical practitioners’ services
1. Registered Dietician

$300 per calendar year

New benefit

  • No prescription required
2. Occupational therapist

$300 per calendar year

New benefit

  • No prescription required
3. Lactation consultant

$300 per calendar year

New benefit

  • No prescription required
  • Services covered by the province or territory of residence must be exhausted first
4. Acupuncturist

$500 per calendar year

  • No prescription required
  • Services can now be provided by a registered acupuncturist and a physician
5. Nurse practitioner

N/A

  • Nurse practitioners can now prescribe medical supplies and prescriptions, if authorized by their provincial or territorial government
  • Contact the province or territory for more information 
Miscellaneous Expenses
6. Batteries for hearing aids

$200 per calendar year

New benefit

  • Batteries continue to be covered under an initial hearing aid purchase
  • This new benefit provides coverage for replacement hearing aid batteries
7. Injectable lubricants for joint pain and arthritis

$600 per calendar year

New benefit

  • Prescription required
8. Gender Affirmation

$75,000 per lifetime

New benefit

  • For certain gender affirming procedures not covered by provincial/territorial health plans to help people transition to the gender they identify with, or to remove gender identity all together
  • To be considered for coverage, the person must:
    • Be aged 18 or older
    • Under the care of a physician for gender transitioning
    • Exhaust all available coverage offered by the province or territory of residence
    • Have all procedures considered medically necessary by the attending physician/ nurse practitioner
    • Obtain prior approval by completing a Gender Affirmation Application Form to be completed by both the covered person and the attending physician/ nurse practitioner and submitted to the plan administrator for review
Medical practitioner’s services
9. Psychological services (Psychologist)

$5,000 per calendar year

Effective July 1, 2023, the PSHCP mental health COVID-19 temporary measures will become permanent.

Increased benefit from $2,000 to $5,000

  • Prescription not required

    Mental health services can now be provided by the following providers in the location in which they work:

    • Psychologists
    • Social Workers
    • Psychotherapists
    • Counsellors, as deemed qualified by the plan administrator based on provincial/ territorial accreditation
  • If $2,000 of claims for psychological services were incurred before July 1, 2023, an additional $3,000 can be claimed for services incurred after July 1, 2023
10. Physiotherapist

$1,500 per calendar year

On July 1st, 2023, the member experience for physiotherapy claims will change. 

  • Prescription not required
  • The member paid corridor between $500 and $1,000 has been removed to provide continuous coverage for up to $1,500 in claims
  • Claims for services incurred between January 1 and June 30, 2023, continue to follow current Plan design
  • Starting January 1, 2024, physiotherapy services can be claimed for services incurred up to $1,500 per calendar year 
11. Massage therapist

$500 per calendar year

Increased benefit from $300 to $500

  • Prescription not required
  • If $300 of massage claims were incurred before July 1, 2023, an additional $200 can be claimed for services incurred on or after July 1, 2023
12. Osteopath

$500 per calendar year

Increased benefit from $300 to $500

  • Prescription not required
  • If $300 of osteopath claims were incurred before July 1, 2023, an additional $200 can be claimed for services incurred on or after July 1, 2023
13. Naturopath

$500 per calendar year

Increased benefit from $300 to $500

  • Prescription not required
  • If $300 of naturopath claims were incurred before July 1, 2023, an additional $200 can be claimed for services incurred on or after July 1, 2023
14. Podiatrist or chiropodist

$500 per calendar year

  • Foot care provided by a licensed nurse in a community nursing station will now be reimbursed under this benefit
  • The services of a podiatrist, chiropodist or a licensed nurse in a community nursing station can be claimed up to a combined maximum of $500 
15. Nursing services

$20,000 per calendar year

Increased benefit from $15,000 to $20,000

  • Must be medically necessary and provided by a licensed nurse in the personal residence of the covered member
  • If $15,000 of nursing services claims were incurred before July 1, 2023, an additional $5,000 can be claimed for services incurred on or after July 1, 2023
16. Electrologist

$1,200 per calendar year

A prescription is required unless the plan participant is undergoing treatment related to gender affirmation.

  • Reimbursement is no longer capped at $20 per visit
17. Speech language pathologist

$750 per calendar year

Audiologists are now included under this benefit.

  • Prescription not required
  • The services of a Speech language pathologist or Audiologist can be claimed to a combined maximum of $750
Vision care
18. Prescription eyeglasses, contact lenses (purchase and repairs)

$400 every two years starting on the odd year

Increased benefit from $275 to $400

  • If $275 of prescription eyeglasses or contact lens claims were incurred before July 1, 2023, an additional $125 can be claimed for purchases/ repairs incurred on or after July 1, 2023
19. Laser eye surgery

$2,000 per lifetime

Increased benefit from $1,000 to $2,000

  • If $1,000 for laser eye surgery was incurred before July 1, 2023, an additional $1,000 can be claimed for services incurred on or after July 1, 2023
Drug benefit
20. Smoking cessation drugs

$2,000 per lifetime

Increased benefit from $1,000 to $2,000

  • If $1,000 for smoking cessation drugs was incurred before July 1, 2023, an additional $1,000 can be claimed for smoking cessation drugs incurred on or after July 1, 2023
Miscellaneous expenses
21. Wigs

$1,500 every 5 years

Increased benefit from $1,000 to $1,500

  • Coverage is for full wigs for total hair loss only
  • If $1,000 for wigs was incurred in the last 5 years, an additional $500 can be claimed for wigs after July 1, 2023, until the end of the 5-year time limit
22. Orthopedic shoes

$250 per calendar year

Increased benefit from $150 to $250

  • Must be prescribed by a physician/ nurse practitioner or podiatrist
  • If $150 for orthopedic shoes was incurred before July 1, 2023, an additional $100 can be claimed for orthopedic shoes purchased on or after July 1, 2023
23. Aerotherapeutic supplies

$500 per calendar year

Increased benefit from $300 to $500

  • Devices, such as CPAP or BiPAP are not covered under the “supplies” benefit. Supplies may include repairs
  • If $300 for aerotherapeutic supplies was incurred before July 1, 2023, an additional $200 can be claimed for aerotherapeutic supplies purchased on or after July 1, 2023
24. Hearing aids

$1,500 every 5 years

Increased benefit from $1,000 to $1,500

  • If $1,000 for hearing aids was incurred in the last 5 years, an additional $500 can be claimed for hearing aids after July 1, 2023, until the end of the 5-year time limit
25. Needles and syringes for injectable drugs

$200 per calendar year

New benefit

  • Prescription required to confirm medical necessity
Diabetes Management
26. Insulin jet injector

$1,000 every 3 years

Increased benefit from $760 to $1,000

  • If $760 for an insulin jet injector was incurred in the last 3 years, an additional $240 can be claimed for an insulin jet injector after July 1, 2023, until the end of the 3-year time limit
27. Continuous Glucose Monitor supplies

$3,000 per calendar year

New benefit - For Type I diabetics only

28. Diabetic monitors

$700 per 5 years

New Benefit. Eligible with or without an insulin pump

  • Prescription required
  • Coverage includes flash glucose monitors, continuous glucose monitors and standard blood glucose monitor devices
  • Continuous glucose monitors are covered for Type I diabetics only
29. Diabetic testing supplies

$3,000 per calendar year

  • Blood testing requirement removed
  • Eligible for all diabetic types
  • Effective July 1, 2023, the full amount of $3,000 for diabetic supplies will be available for the remainder of 2023
  • Continuous Glucose Monitors supplies are not covered under the diabetic testing supplies benefit.

 

Durable Equipment
30. Walkers and wheelchairs

No change

No longer restricted for use in a private residence only

  • As of July 1, 2023, a new wheelchair purchased within the 5 year time limit may be eligible when the plan participant’s medical condition changes and requires a different type of chair  
  • Reimbursement will be for the amount of the new chair less the amount reimbursed for the previously claimed chair (if claimed within the same 5-year period)
31. Medical monitoring devices

Limited to one every 5 years

A prescription is required

  • In addition to apnea and enuresis monitors, the following devices are now covered when determined medically necessary:
    • Oxygen saturation meter
    • Pulse oximeter
    • Saturometer
    • Blood pressure monitor
    • Coagulation monitor
    • Heart monitor
Hospital Coverage for members with Supplementary Coverage
32. Level I

$90 per day

Increased benefit from $60 to $90

33. Level II

$170 per day

Increased benefit from $140 to $170

34. Level III

$250 per day

Increased benefit from $220 to $250

Out-of-province benefit
35. Emergency benefit while travelling

$1 million per trip

Increased benefit from $500,000 to $1 million

  • Out-of-province coverage for 40 consecutive days, excluding any time out of the province for business on official travel status
36. Family Assistance Benefits

$5,000 per travel emergency

  • Increased benefit from $2,500 to $5,000
  • Increased meals and accommodations benefit from $150 to $200 per day

 

Relief provision
37. Pensioner relief provision

N/A

Relief provision extended to include members who retire after April 1, 2015, extended until March 31, 2025, provided they meet the following criteria:

  • In receipt of a Guaranteed Income Supplement (GIS) benefit or
  • Has a net or combined net income lower than the GIS thresholds
PSHCP Changes
Benefit Details
38. Mandatory Generic Drug Substitution

The PSHCP will implement Mandatory Generic Drug Substitution following a legacy period ending December 31, 2023.

  • During the legacy period, prescribed brand name drugs will still be reimbursed at 80% of their cost for those with existing prescriptions
  • New prescriptions will be subject to mandatory generic drug substitution as of July 1, 2023
  • After the legacy period, all prescription drugs covered under the PSHCP will be reimbursed at 80% of the cost of the lowest-priced alternative generic drug
  • If a person cannot take the generic version of the drug they are prescribed, due to a medical reason, they may still be covered for the brand name drug, reimbursed at 80%
    • Exceptions will be considered based on medical necessity.
    • A Brand Name Drug Coverage form must be completed by the attending physician/ nurse practitioner and submitted to the plan administrator for review
39. Prior Authorization & Biosimilars

A Prior Authorization program will be implemented effective July 1, 2023, for a sub-set of specific prescription drugs that require special handling. For example, specialty drugs or drugs that are administered by a medical professional in a clinical setting.

Prior Authorization is a process administered by the plan administrator where certain drugs need to be pre-approved before they are reimbursed under the PSHCP. It is an evidence-based program to ensure members are receiving reasonable treatment and is supported by medical professionals at Canada Life.

  • Prior to July 1, 2023, if a member is on any of the prescription drugs that are part of the Prior Authorization program, they will not be required to go through the Prior Authorization process and their coverage will continue. However, members may need to switch their existing biologic drug to a biosimilar drug (members in this situation will be contacted directly by Canada Life) *see below
  • After July 1, 2023, if a member is prescribed, for the first time, a drug that is on the Prior Authorization list, they will be required to go through the Prior Authorization process to have the medication pre-approved for reimbursement under the PSHCP
    • A Request for Information form must be completed with the attending physician/ nurse practitioner and submitted to the plan administrator for review.
  • The prescription drugs on the Prior Authorization list will be posted on the new Canada Life PSHCP Member services website

* Biosimilars:

Biosimilars, comparable cost-effective versions to original biologic drugs, are proven to be as safe and effective as biologics.  

  • After July 1, 2023, if a person is on a biologic drug where there is a biosimilar available, the plan administrator will contact them directly with transition details 
  • For new prescriptions, when available, biosimilars will be favored
  • Exceptions will be considered based on medical evidence.
    • An Originator Biologic Drug Form must be completed by the prescribing physician/ nurse practitioner and submitted to the plan administrator for review providing medical evidence confirming the reasons why
40. Compound Drugs

The PSHCP will implement a change to compound drug eligibility following a legacy period ending December 31, 2023.

  • During the legacy period, compound drugs without at least one active ingredient with a Drug Identification Number (DIN) that is covered under the PSHCP will still be reimbursed for those with existing prescriptions
  • New prescriptions will be subject to the new compound drug eligibility as of July 1, 2023
  • After the legacy period, all compounds will be subject to the new compound drug eligibility
41. Catastrophic Drug Coverage

Effective July 1, 2023, eligible drug expenses will be reimbursed at 100% when out-of-pocket drug expenses exceed $3,500 in a calendar year.

  • Increased out-of-pocket from $3,000 to $3,500 eligible drug expenses will be reimbursed at 80%, until a plan member reaches, in that same calendar year, $3,500 in out-of-pocket eligible drug expenses, at which point, the plan member will be reimbursed at 100%
  • If $3,000 of out-of-pocket drug expenses were incurred before July 1, 2023, an additional $500 of out-of-pocket drug expenses must be incurred to receive 100% reimbursement for purchases made after July 1, 2023
Pharmacy Dispensing Fees
42. Frequency Limits

Effective July 1, 2023, pharmacist dispensing fee will be reimbursed up to a maximum of five times per year for maintenance drugs. Exceptions will be considered in situations such as:

  • There are safety concerns with the prescribed drug
  • There are storage limitations for the prescribed drug (e.g. requiring deep freeze temperatures)
  • The prescribed drug’s 3-month supply co-pay is more than $100

Exceptions may apply to some provinces/territories due to pharmacy regulations

43. Fee Caps

Effective July 1, 2023, the PSHCP will reimburse up to a maximum of $8 for the pharmacy dispensing fee.

  • The dispensing fee cap will not apply to specialty or compound drugs
  • Exceptions may apply to some provinces/territories due to pharmacy regulations

The PSHCP Directive is currently being updated to reflect the above changes. It will be available effective July 1, 2023. At that time, should there be any discrepancy between the information in this Information Notice and that contained in the PSHCP Directive, the PSHCP Directive applies.

Effective July 1, 2023, plan members can speak with the plan administrator, Canada Life, regarding any details surrounding these plan changes.

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