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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 Dietitian $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
5. Nurse practitioner N/A
  • Nurse practitioners can now prescribe medical supplies and prescription drugs, 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
  • Not eligible for cosmetic purposes
8. Gender Affirmation $75,000 per lifetime New benefit
  • For certain gender affirming procedures not covered by provincial/territorial health plans to help people with their gender affirmation journey
  • To be considered for coverage, the person must:
    • Be aged 18 or older
    • Under the care of a physician for gender affirmation
    • 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
  • Starting January 1, 2024, psychological services can be claimed up to $5,000 per calendar year
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
  • After July 1, 2023, the full amount of $1,500 will be available for the remainder of 2023
  • Starting January 1, 2024, physiotherapist 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
  • Starting January 1, 2024, massage therapist services can be claimed up to $500 per calendar year
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
  • Starting January 1, 2024, osteopath services can be claimed up to $500 per calendar year
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
  • Starting January 1, 2024, naturopath services can be claimed up to $500 per calendar year
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
  • If $300 of podiatrist or chiropodist claims were incurred before July 1, 2023, an additional $200 can be claimed for services incurred on or after July 1, 2023
  • Starting January 1, 2024, podiatrist or chiropodist services can be claimed up to $500 per calendar year
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
  • Starting January 1, 2024, nursing services can be claimed up to $20,000 per calendar year
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 and audiologist $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
  • Starting January 1, 2025, prescription eyeglasses or contact lenses can be claimed up to $400 every two years
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 continues to be for full wigs when a member experiences total hair loss
  • If $1,000 was claimed for wigs 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
  • Starting January 1, 2024, orthopedic shoes can be claimed up to $250 per calendar year
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
  • Starting January 1, 2024, aerotherapeutic supplies can be claimed up to $500 per calendar year
24. Hearing aids $1,500 every 5 years Increased benefit from $1,000 to $1,500
  • If $1,000 was claimed for hearing aids in the last 5 years, an additional $500 can be claimed for hearing aids purchased on or 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
  • The prescription will be valid for 3 years
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 claimed in the last 3 years, an additional $240 can be claimed for an insulin jet injector purchased after July 1, 2023, and until the end of the 3-year time limit
27. Continuous Glucose Monitor supplies $3,000 per calendar year New benefit for people with Type I diabetes 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 glucose monitor devices
    • Continuous glucose monitors are covered for people with Type I diabetes only
  • Blood testing requirement removed
29. Diabetic testing supplies $3,000 per calendar year
  • 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 Monitor 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
* Coverage reimbursed at 100%
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
* Coverage reimbursed at 100%
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, if processed electronically at the pharmacy using the PSHCP Benefit Card
  • New prescriptions will be subject to mandatory generic drug substitution as of July 1, 2023
  • As of January 1, 2024, 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%, if processed electronically at the pharmacy using the PSHCP Benefit Card
    • Exceptions will be based on the plan administrator’s assessment of 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, biologic 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 the plan administrator’s medical professionals.

  • 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 to continue receiving that prescription. 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 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 PSHCP Member services website
* Biosimilars:
Biosimilars, comparable cost-effective versions to originator biologic drugs, are proven to be as safe and effective as originator biologics. 
  • Starting July 1, 2023, and over the following 2 years, if a plan member is on a biologic drug where there is a biosimilar available, the plan administrator may contact the member directly with transition details 
  • For new prescriptions, when available, biosimilars will be favoured
  • 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 to support any exception requests
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
  • As of July 1, 2023, new compound drug prescriptions will require at least one active ingredient to have a DIN that is covered under the PSHCP
  • Until January 1, 2024, members who were reimbursed for a compound drug, regardless of ingredient, between January 1, 2023, and June 30, 2023, can have a subsequent compound drug (for that same compound drug) reimbursed without the need for one active ingredient to have a DIN
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 in 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 fees will be reimbursed up to a maximum of five times per year for maintenance drugs. Exceptions will be considered in situations such as:

  • Safety concerns with the prescribed drug (e.g. controlled substance, compliance packaging/ blister packs)
  • 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, reimbursed at 80%, for the pharmacy dispensing fee.
  • The dispensing fee cap will not apply to biologic 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 this 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 new plan administrator, Canada Life, regarding any details surrounding these plan changes.

Plan members are encouraged to keep medical receipts and records for at least one year following treatment or purchase of medical equipment and supplies and may be required to submit documentation to support claims as required by the plan administrator.

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