Update on the Public Service Health Care Plan Transition

Important! As of January 1, 2024, all members of the PSHCP will be subject to mandatory generic substitution for prescription drugs. Find out what this means for you.

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Improving services to members

We recognize many Public Service Health Care Plan (PSHCP) members continue to experience long wait times or are having difficulties with their claims.

The Government of Canada continues to meet with Canada Life representatives daily to seek solutions to improve the member experience.

Canada Life’s action plan

Canada Life recently presented an action plan for addressing these concerns. They have committed to:

  • extending call centre hours by opening on weekends as of November 4, through to December 17
  • introducing an urgent needs escalation process (canadalife.com) for priority cases, starting on November 6
  • reducing call centre wait times to 5–10 minutes by December

This builds on steps already taken to improve service to plan members, including increasing call centre staff by over 50% since July. These actions should provide members with noticeably better service, and the government will continue to press for additional improvements.

Canada Life has updated their frequently asked questions (canadalife.com) to help plan members and relieve pressure on their call centre. Canada Life will continue to update this page in the coming weeks.

Meeting service standards

The Government of Canada is continuing to work with Canada Life to ensure that solutions are implemented as quickly as possible and members get the service they deserve.

As of January 2, 2024, Canada Life will be fully obligated to meet a minimum service standard for their call centre wait times.

Changes to the Public Service Health Care Plan

Effective July 1, 2023, changes to the PSHCP were implemented. These changes were negotiated at the PSHCP Partners Committee, comprised of the Government of Canada, bargaining agents, and retiree representatives under the umbrella of the National Joint Council.

The plan changes feature:

  • 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
  • market-tested cost saving measures intended to ensure the long-term sustainability of the plan and align with industry standards

For the full listing of improvements and changes, please review the Update: Improvements and changes to the PSHCP Information Notice. For more information on the PSHCP, visit PSHCP Member booklet at-a-glance (canadalife.com) and the PSHCP Directive.

Below, we have highlighted some of the significant changes. 

Prior authorization

On July 1, 2023, the PSHCP introduced a prior authorization program. Under this program, certain prescription drugs require approval from Canada Life before they can be reimbursed, for example, biologic drugs that are administered by a medical professional in a clinical setting.

Prior authorization is a standard practice in the health care plan industry. Prior authorization asks members to use less expensive treatments where they are equally effective and medically appropriate. This helps reduce costs and ensure sustainability of the plan over the long term.

Note, a grandparenting clause was included so that if a PSHCP member was on a prescription drug prior to July 1, 2023, they will not be required to go through the Prior Authorization process to continue receiving the same drug. 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).

To see if your prescription requires approval under the prior authorization program, consult the list of medications in your account on Canada Life’s PSHCP Member Services website. If it does, ask your health care provider to fill out the prior authorization form (canadalife.com) as required.

For more information on Prior Authorization

Mandatory generic substitution of prescription drugs

The PSHCP provides coverage for eligible prescription drugs at 80%. On July 1, 2023, a mandatory generic drug substitution came into effect for all new prescription drugs under the PSHCP. This means that you and your 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 the brand name drug as they contain identical medicinal ingredients. Mandatory generic substitution is a standard in the health care plan industry. This change will help to ensure the continued sustainability of the PSHCP.

PSHCP members who were prescribed brand name drugs prior to July 1, 2023, will continue to be reimbursed at 80% of the eligible brand name drug cost until December 31, 2023. Starting January 1, 2024, the PSHCP will cover 80% of the lowest-cost generic drug when a generic is available, unless the member has an exception on file.

If you are prescribed, or are currently taking a brand name drug, you have 3 options come January 1, 2024:

  1. Switch to the lowest-cost alternative generic drug and be covered for 80% of the cost of that drug 
  2. Ask your 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
  3. Discuss the issue with a medical professional: If they believe that the brand name drug is required, ask them to complete the PSHCP Request for brand name drug coverage form (canadalife.com) and submit it to Canada Life—if approved, you will be covered for 80% of the eligible cost of the brand name drug

For more information on Mandatory Generic Drugs

Pharmacy dispensing fee cap

Pharmacies charge a dispensing fee every time they fill a prescription. Prior to July 1, 2023, the PSHCP covered 80% of the dispensing fee. Effective July 1, 2023, members are reimbursed up to a maximum of $8, covered at 80%, for the pharmacy dispensing fee up to a maximum of 5 times per year for maintenance drugs.

The dispensing fee cap will 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.

For more information on Dispensing Fees

Physiotherapy coverage

Effective July 1, 2023, changes were made to physiotherapy coverage to expand access and coverage for the vast majority of plan members and their eligible dependants. Plan members no longer need to pay for service amounts between $500 and $1,000 for physiotherapy and no longer require a prescription.

A new annual maximum of $1,500, reimbursed at 80%, was introduced to better align with industry standards. The new annual maximum provides an amount that is more than double the industry average of $700 while the elimination of the service amounts between $500 and $1,000 allows more members to benefit from additional physiotherapy coverage.

PSHCP members and their eligible dependants are encouraged to explore options with their province/territory for coverage as part of their physical rehabilitation plan, in addition to utilizing the new and expanded coverage options under the PSHCP (osteopathy, occupational therapist, etc.).

Transition period

To assist plan members with larger physiotherapy needs in the transition to the new annual maximum, between July 1, 2023, and December 31, 2023, regardless of the amount claimed prior to July 1, 2023, plan members can utilize the full amount of $1,500 in physiotherapy services. The $1,500 annual maximum will reset on January 1, 2024.

For more information on Physiotherapy Coverage

Denied claims

With the transition to a new PSHCP administrator, as well as changes to certain benefits, some members are experiencing difficulties with the administration of their claims. In some cases, wait times for processing of claims may have been longer than expected and some claims approved by the previous administrator may have been denied.

We are working with Canada Life to better understand these situations and, where appropriate, find quick resolutions.

Much of Canada Life’s claims processing is fully automated, meaning members should see their claims processed quickly and efficiently. Where a claim needs to be assessed manually, for example, for claims submitted by paper or complex cases, Canada Life will review the information provided by the plan member and may request additional supporting documents before they can finalize processing the claim.

As of November 6, 2023, an urgent needs escalation process (canadalife.com) is available for those needing 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.

We have outlined below when to use the urgent escalation process and when to use the appeals process.

Urgent escalation process

If your claim is for urgent, life-sustaining prescription drugs, services, or treatments (such as mechanical ventilation, renal dialysis or insulin, cancer drugs or artificial nutrition and hydration supplies like feeding tubes) or you are a person with a disability, follow these steps:

  1. 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 coverage changes
  2. After reviewing the directive and determining the item should be covered, you may contact the escalation team by email at Urgent_PSHCP@canadalife.com
  3. As this is not a secure email channel, ensure to only include your plan and certificate number, as well as a brief explanation (1–2 sentences) for the escalation

Appeals process

For concerns with a denied claim, members should take the following steps:

  1. 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 changes that may be impacting the claim
  2. If the question or concern is still not answered, contact Canada Life (canadalife.com) to find a resolution or explanation
  3. If still unsatisfied with the claims decision, you may 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 (for example: level of coverage, waiting period or refund of contributions), and wish to have their file reviewed. The Appeals Committee reviews each appeal on a case-by-case basis.

Next steps

The Government of Canada is committed to working with Canada Life to ensure that solutions are implemented as quickly as possible.

We’ll be providing more details in the coming days and weeks on what actions are being taken to improve service standards, as well as helpful information to support plan members.

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