Update on the Public Service Health Care Plan
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Improved services to members
On July 1, 2023, Canada Life became the new administrator for the Public Service Health Care Plan (PSHCP). Transitioning 1.7 million federal public servants, retirees and their eligible dependants to a new administrator was a large undertaking and resulted in some plan members experiencing service delivery challenges.
Over the last year, the Government of Canada has worked with Canada Life to ensure solutions were implemented as quickly as possible to address these challenges.
Meeting service standards
Since November 2023, when Canada Life implemented their customer service action plan, there have been significant improvements in call centre and claims processing wait times.
Members’ calls are now being answered, on average, in less than 30 seconds, and digital claims are being processed within 1 business day. Additionally, although some complex and paper-based claims take a bit longer to be processed, Canada Life is typically processing them within 4 business days.
MSH International
Canada Life continues to work with MSH International, their sub-contractor for out-of-province and out-of-country coverage and service, to ensure members get the services they need. Together, they have made significant progress on claims adjudication and call centre wait times.
Following implementation of a similar action plan as Canada Life, MSH:
- hired additional call centre and claims agents to decrease the average wait times
- leveraged Canada Life’s urgent needs escalation process (canadalife.com) for priority cases
- created an online dashboard (canadalife.com) to show claims processing and call centre wait times
- enhanced the online MSH PSHCP Member portal (pshcp-msh.ca) experience with many improvements, including a restructured landing page and updated claims submission process for members with comprehensive coverage, making it easier to file claims online
- created a dedicated email address and telephone line option for health care providers
As a result of these actions, since July 2024, the average MSH call wait time for members is now less than 2 minutes. This represents a wait time decrease of over 90% since winter 2023.
At the same time, the claims inventory has been reduced by 98% since its peak in the spring. As Canada Life receives new claims every day, it is important to note that the inventory will never be completely eliminated. However, the majority of claims are now processed within 11 business days, after all documentation is received.
The Government of Canada and Canada Life remain focused on further improving the member experience, particularly through reducing MSH claims processing times and updating the MSH PSHCP Member portal.
Changes to the Public Service Health Care Plan
Changes to the PSHCP were implemented on July 1, 2023, and included increased support for mental health and well-being, new supports that benefit seniors, families, young adults, persons with disabilities, and members of the 2SLGBTQI+ community.
We have highlighted the significant changes below.
Prior authorization
A prior authorization program has been in effect since July 1, 2023, and is a standard practice in the health care plan industry. This means that certain prescription drugs require approval from Canada Life before they can be reimbursed.
If a member is prescribed a drug that requires Prior Authorization, the Prior Authorization process must be completed to have the medication pre-approved for reimbursement. For a listing of the prescription drugs that require Prior Authorization: PSHCP Member Services (canadalife.com).
A grandparenting clause was included for members or eligible dependants who were on a prescription drug prior to July 1, 2023, and as a result, there is no need to go through the Prior Authorization process to be reimbursed for the same drug.
Mandatory generic substitution
The PSHCP provides coverage for eligible prescription drugs at 80%. On July 1, 2023, mandatory generic drug substitution came into effect for all new prescription drugs under the PSHCP. This means that members and eligible dependants will be reimbursed at 80% for the cost of the lowest-cost generic equivalent.
Generic drugs are approved by Health Canada and are pharmaceutically equivalent to brand name drugs as they contain identical medicinal ingredients. Mandatory generic substitution is a standard in the health care plan industry and will help to ensure the continued sustainability of the PSHCP.
If members are prescribed, or are currently taking a brand name drug, there are 3 options:
- Switch to the lowest-cost alternative generic drug and be covered for 80% of the cost of that drug
- Ask the pharmacist for the brand name drug and pay the difference between the cost of the brand name drug and 80% of the cost of the generic drug
- Discuss the issue with a physician or nurse practitioner:
- If it is determined the brand name drug is required, members will need to complete the PSHCP Request for brand name drug coverage form (canadalife.com) and submit it to Canada Life
- If the request is approved, 80% of the eligible cost of the brand name drug will be covered
Pharmacy frequency limits and dispensing fee cap
Pharmacies charge a dispensing fee every time they fill a prescription.
Since July 1, 2023, members are reimbursed for:
- 80% of a maximum of $8 in dispensing fees
- a maximum of 5 dispensing fees per year for maintenance drugs
The dispensing fee cap of $8 does not apply to biologic or compound drugs and exceptions may apply in some provinces/territories in keeping with pharmacy regulations.
Dispensing fees can vary by pharmacy, so members may want to do a cost comparison to reduce out-of-pocket costs.
Physiotherapy coverage
Changes to physiotherapy coverage were implemented to expand access and coverage for the majority of plan members and eligible dependants. The annual maximum of $1,500 in continuous coverage, reimbursed at 80%, aligns with industry standards and provides for more than double the industry average of $700.
Improvements such as the removal of the member-paid corridor between $500 and $1000, and the elimination of the prescription requirement allow more members to easily access and benefit from physiotherapy coverage.
PSHCP members and eligible dependants are encouraged to explore provincial and territorial physiotherapy coverage options, in addition to utilizing the expanded coverage options under the PSHCP (osteopathy, occupational therapist, etc.).
Urgent escalation process
An urgent needs escalation process (canadalife.com) is available for those needing help with urgent, life-sustaining products or services. This process is also available to persons with disabilities who may have difficulties attending appointments with health care professionals or require additional support.
- If a prescription drug, product or medical service that was previously covered is declined, first check the Public Service Health Care Plan Directive to confirm if there have been plan design changes that may be impacting the claim
- After reviewing the directive and determining the item is eligible for coverage, contact the Canada Life escalation team by email at Urgent_PSHCP@canadalife.com
- As this is not a secure email channel, include only the plan and certificate number, with a brief explanation (1–2 sentences) for the escalation
Appeals process
- Review the Public Service Health Care Plan Directive and the Update: Improvements and changes to the Public Service Health Care Plan to ensure familiarity with plan design changes that may be impacting the claim.
- If the question or concern is still not answered, contact Canada Life (canadalife.com) for a resolution or explanation.
- If still unsatisfied with the decision, submit an appeal to the Federal PSHCP Administration Authority (pshcp.ca).
The appeals process is available to all PSHCP members who do not agree with a decision regarding their claim, benefit entitlement or coverage. The Appeals Committee reviews each appeal on a case-by-case basis.
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