Public Service Healthcare Plan FAQ

Most active and retired PIPSC members who work in the Core Public Administration or at a separate agency are covered by this plan. Consult your group page if you do not know which health plan you are covered by.

The Institute supports members by explaining Canada Life and Treasury Board policies, by proposing strategies to make the best use of your benefits, and by guiding members through appeals. During the transition to an updated plan and a new plan administrator, PIPSC is also providing member education; however, your first resource for plan information should be the PSHCP website, which will be updated with information on changes as they become available.

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The updated plan will be administered by Canada Life (the current provider of the dental plan) on a go forward basis as of July 1st 2023. Canada Life won a bidding process to take over the PSHCP. It is purely coincidental that the updated plan and new provider start date fall on the same date. Until the handover, Sunlife remains the plan administrator.

You will need to complete a positive enrolment form from Canada Life.  If you are already registered with Sunlife, Canada Life will contact you via email or mail between March and late April using your contact information registered with your existing Sunlife account.  If you are not contacted by the end of April, you may contact Canada Life at 1-855-415-4414 to enrol.

Note the policy number for surviving dependants (spouse and eligible children) is 52115.  Policy numbers are also called plan numbers.

Once you have completed the positive enrolment form with Canada Life, you should be able to access your health plan profile through Canada Life.  If you do not yet have online access to your Canada Life account, you may create a profile at www.canadalife.com/pshcp.

Yes.  Once your positive enrolment form is processed, your online Canada Life account will prompt you to go to the dental plan or health plan after logging in.

No. The plan is still the same plan – just with new limits and a new administrator. The policies and limits in place on the day an expense is incurred will remain in effect. For example, if you accumulate $500 in massage expenses prior to July 1st, you will be eligible to claim $300 (current limit) at 80% reimbursement. On July 1st, you will have an additional $200 to spend in the calendar year (2023).  Note that you cannot resubmit the $200 incurred prior to July 1st for reimbursement as the new limit is on a go-forward basis only.

Exceptionally, on July 1st 2023 physiotherapy benefits will reset.  This is a one-time exception in 2023 alone.

The directive and any other member information is currently being revised. Information will be posted on various websites as soon as it becomes available. As always, the PSHCP website is your best resource for information.

The PSHCP is a self-insured benefit plan – meaning the costs of the plan are entirely paid by contributions (Canada Life is not actually insuring anything). The plan administrator is responsible for reimbursing and adjudicating claims. They are also in charge of determining most administrative procedures. For most members, the updated plan administrator won’t change much other than which website or app you use to claim expenses. That said, some procedures might change slightly – like the type of form you need to use to enrol your spouse or the criteria for coverage for a special medical product. These administrator procedures are currently being developed by Canada Life and will be communicated with members closer to July 1st 2023. Most changes will be very minor in nature.

While Pensions & Benefits are non-negotiable under the Treasury Board’s interpretation of federal public service labour law, they have adopted a collaborative approach to reviewing its benefit plans. The Partners’ Committee of the Public Service Healthcare plan (made up of union, retiree, and employer representatives), and its renewal committee, have been meeting for the past few years to discuss changes to the plan. Changes are based on an independent review of medical best practices, benchmarking studies comparing coverage to other large plans, member needs/preferences, and financial sustainability. PIPSC also brings forward information gathered through a member survey conducted in 2017 as well as ongoing feedback from our members.

The plan has not been meaningfully reviewed since 2006; however, minor improvements have been introduced over this period.  As part of this most recent review process, Union and Retiree representatives have asked for the Treasury Board’s commitment to a more regular review process. We have asked for a four year review cycle.

Yes. Plan changes have been approved by the Partners’ Committee and the Treasury Board Secretariat.

Because benefits are non-negotiable under the law, PIPSC cannot take strike action or certain legal approaches to change the plan. Instead, the PSHCP is reviewed by balancing member needs, costs, and what other large employers are doing. Generally, this plan exceeds benchmarked plans in terms of drug coverage, speciality services, and the range of services/products covered; however, it falls in the middle-ground on spending caps for healthcare providers and certain products like vision care.

As this is a fully employer paid plan, which has seen plan costs explode over the past decade due to a total lack of drug coverage strategy, the President of the Treasury Board originally asked plan changes to be cost-negative. In other words, any improvements to coverage must be paid for by double cost savings elsewhere. We called on the Minister to adopt a more reasonable approach that would give greater room to reinvest the entirety of cost savings elsewhere in the plan. The Treasury Board eventually agreed that plan changes would be cost neutral. This has allowed the plan to reduce spending on medically unnecessary or inflated drug costs and reinvest these savings where they actually make a difference to your health and wellness.

We note that retirees pay fifty percent of plan premiums, unless they are covered by the recently renewed low-income protections.

Lots! Many caps have increased significantly, new providers have been added, administrative requirements have been eased, and coverage for various services has been expanded. This updated plan offers members improved access to evidence-based healthcare services at the same reimbursement rate (80 percent) as before. There are changes to how drugs are covered to reduce spending on pharmacist fees and clinically less appropriate medications. A full list of changes will be published at a later date on the PSHCP website.

The plan’s design is largely determined via benchmarking to comparable plans. No comparable plans offered such an extensive benefit. This was also flagged as an item subject to a high degree of fraud and abuse (providers overtreating a condition/inflating treatment plans).

Under the updated plan, the member-paid corridor ($500 deductible) will be removed. This means that members will receive 80 percent reimbursement on the first $1500 of physiotherapy they claim each year – this is an improvement. We believe the $500-$1000 corridor meant that some plan members were foregoing preventative physiotherapy care to avoid out of pocket costs. The new $1500 limit is expected to result in greater use of physiotherapy than before and, we hope, a more proactive approach to health; however, we understand that a greater benefit for more members comes at the expense of more comprehensive coverage for those with chronic conditions.

Members who are negatively impacted by this change may wish to identify publicly-funded provincial/territorial physiotherapy programs which, generally, cover the conditions leading to frequent use of physiotherapy providers. These programs are often run by hospitals or specialty rehabilitation programs in your local community.

We also note the plan has also introduced several new provisions that provide treatment that may reduce the need for physiotherapy such as:

• Injectable lubricants for joint pain and arthritis at $600 per calendar year
• Occupational therapy at $300 per calendar year
• Acupuncture at $500 per calendar year as performed by an acupuncturist
• Osteopath at $500 per calendar year

**While the Treasury Board has not been amenable to a catastrophic physiotherapy coverage as requested, ongoing lobbying from union and retiree representatives was successful in adopting an exceptional transitory measure for 2023.  This year (and only this year) the physiotherapy allowance will reset on July 1st.  This means that plan members who, for example, claim $3000 for physiotherapy in the first half of 2023 will be eligible for another $1500 in the second half of the year.  This exceptional measure only applies to physiotherapy in 2023.**

Under the updated plan, acupuncturists will be eligible at up to $500 per calendar year. No prescription is needed. Previously, only acupuncture performed by a medical doctor was covered.

Massage therapy has increased from $300 to $500 per calendar year. This is a very high-use item, meaning that any increase would be very costly. Members do have access to an expanded range and increased cap for many physical health providers and may choose to take advantage of a multidisciplinary approach to maximize their recovery and wellness.

The cap for Psychological Services is being increased to $5,000 per calendar year from $2000. Eligible mental health services will, generally, include:

• Psychologists
• Psychotherapists
• Social workers
• Registered counsellor
• Family Therapist
• Sexologists

The types of covered healthcare professionals vary by province due to provincial regulations.  Generally, any mental healthcare provider belonging to a provincially accredited professional order which requires practitioners to have master degrees and that is permitted to issue receipts which are tax deductible as medical expenses will be covered. Detailed information on covered providers will be made available at a later time.

Vocational guidance counsellors in Quebec who are also registered as a psychotherapist will almost certainly be eligible under the mental health benefit provided they issue receipts with their psychotherapists number. Coverage for vocational guidance counsellors without accreditation as a psychotherapist is not yet determined, but, due to current taxation rules, is unlikely.

Yes. This is a new benefit, you will have $300 per calendar year to use towards the services of a Lactation Consultant. No prescription is required.

Yes. This is a new benefit, you will have $300 per calendar year to use towards the services of a Registered Dietician. No prescription is required. Some departments/separate employers also offer this benefit for free via their Employee Assistance Program.

Yes. This is a new benefit, you will have $300 per calendar year to use towards the services of an Occupational Therapist. No prescription is required

As always, the provider must be provincially accredited to practise their profession and remain a provider in good standing with the plan administrator. Canada Life publishes a list of providers who are not eligible for reimbursement due to concerns about fraud, records keeping, or professional standards. This list is likely to be extremely similar to the existing Sunlife list available through the Sunlife portal.

• Osteopathy, naturopathy, and podiatry is increasing to $500.
• Speech language is moving to $750 and will include audiologists.
• Nursing increases to $20000.
• Foot care provided by community nurses will be eligible under the podiatry benefit.
• Electrolysis coverage will change from a per session limit of $20 to reasonable and customary (as established by Canada Life) with an annual maximum of $1200. Electrolysis will not require a prescription for gender-affirmation care.

Transgender members will be eligible for a range of gender affirming procedures not covered by their provincial or territorial healthcare plan to a lifetime cap of $75,000. The specific treatments covered under this benefit are still being developed, but are likely to include things like vocal surgery, facial bone reduction, and jawline augmentation. We are immensely proud to have achieved this extremely low-cost benefit that makes such an important difference in the lives of some of our members.

Currently the plan covers almost every drug authorised by Health Canada – regardless of the quality, effectiveness, or appropriateness for your situation. The plan also has very limited terms around reasonable and customary costs for medication – meaning excessive markup and/or dispensing fee costs are borne by the plan. This has led to a massive increase in drug spending inappropriate to other health plans with limited member benefits. To address this, the plan will be introducing new rules around dispensing fees and frequency as well as coverage for an extremely small range of high cost or irregular medications.

Surprisingly to most, the government does not, generally, regulate the cost or superiorness of prescription medications in Canada. Approved drugs are indeed extensively tested for safety, side effects, and that they are treating what they say they are; however, an approved drug is not necessarily better than what is already on the market. Pharmacies are also, generally, free to charge what they want for a medication. Only some provinces regulate prices at the retail level, and those regulations are very general. This means the exact same generic medication can cost triple or more simply by going to the wrong pharmacy.

This allows for eligible drug expenses to be reimbursed at 100% when out-of-pocket drug expenses incurred exceed a certain limit. This limit is increasing from $3000 to $3500 – the first increase since 2006.

Any drug covered under this plan automatically falls under this clause.

Yes; however the mandatory generic substitution program will become stricter. The current plan will only cover the cost of a brand name medication when the prescription states no substitutions are permitted. Under the updated plan, it will become necessary to justify the reasoning for no substitutions (ex: allergy to an ingredient).

Currently, the plan has an unusually high number of claims where no-substitutions are allowed. This does not correspond to medical evidence of what should be expected from a plan member population like the PSHCP. By introducing this stricter program, members will still have access to name brand drug coverage when it is truly necessary.

The first 180 days of the updated plan, starting July 1st, 2023, previously covered prescribed brand name drugs will still be reimbursed at 80% of their cost.

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 unless an exception claim is approved.

Details on the exception process will be made available by Canada Life at a later time

Generic drugs use the exact same active ingredient(s) as the name brand medication, but may vary in filler and carrier ingredients. In almost every scenario, a brand-name medication can be seamlessly substituted by a generic. If you have concerns, you can speak to your pharmacist for additional information. In the extremely rare case that the available generic form is not suitable for you, Canada Life will have an exception process to allow for coverage of the name brand.

Drugs still under patent will be covered at the brand-name price as per usual. As is standard in the industry, members will not be informed when a generic version is available; however, most pharmacists will automatically switch you to the generic. Note that Canada Life has a grace period of a few months between a generic becoming available and the requirement to fill as a generic.

Yes. You can choose to fill the name brand but will need to cover the difference in cost.

Effective July 1, 2023, the PSHCP will reimburse up to a maximum of $8 for the pharmacy dispensing fee. This amount was determined based on the average dispensing fee in Canada.

The fee cap will not apply to biologic or compounded drugs. Certain specialty drugs may also be exempt. Caps on dispensing fees/fill frequencies means members pay less out-of-pocket if they choose to fill wisely. Pharmacist dispensing fees will be reimbursed up to a maximum of five times per year for maintenance drugs.

Note that due to how prescription medications are charged in Quebec, this cap will not apply to medications dispensed in Quebec.

Yes. Generally, pharmacists are free to charge whatever dispensing fee and medication markup they choose. This has seen certain pharmacies, especially retail-chains, charge significantly more than competitors who offer similar or identical services.  With a dispensing fee cap,  plan members frequenting a pharmacy that charges more than the cap can decide if they wish to cover the excess fee or transfer their prescriptions to a lower-cost pharmacy.

We suggest considering low-cost warehouse clubs (no membership required for pharmacy services) or mail-order pharmacies that, generally, offer the exact same services as a community pharmacy without the significant markup that some retail pharmacies charge. PIPSC has signed a partnership with the online pharmacy Mednow which offers exceptional savings on medications delivered to your door –  including refrigerated and controlled medications. Mednow is offering all PIPSC members and their dependants a ten percent rebate on prescription drugs.  This effectively means that your copay is cut in half – from twenty to ten percent.  This preferential rate will be launched through the serviceplus portal in early 2023 and, due to provincial regulations which prohibit preferential drug pricing, is not available for medications shipped to Quebec addresses.

Under the updated plan, maintenance drugs (long-term medications for things like blood pressure, depression, or stomach hyperacidity) will need to be filled for three months at a time to maximise out-of-pocket savings. Filling medication for longer intervals saves on dispensing fees and, sometimes, drug markup fees. The plan will cover up to five dispensing instances per year for maintenance medications. Members who chose to dispense maintenance medications in shorter intervals (ex: monthly) will still be eligible for coverage; however, they will cover any additional costs as a result of the shorter intervals.

Exceptions will be granted if:

• There are safety concerns with the prescribed drug (e.g. controlled substance)
• 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
• The medication is dispensed in the province of Quebec (due to provincial regulations)

Mednow is offering serviceplus (all PIPSC members) members preferential rates on prescription medication.  With Mednow, ten percent of the drug price is rebated, meaning you effectively get 90 percent coverage on your medication.

Due to government regulations, note that this rebate is not provided on medications shipped to Quebec and that Mednow must charge all customers (outside Quebec) the same $8.99 dispensing fee of which 99 cents will not be covered by your health plan.  This is taken into account in the above savings chart.

Mednow is a licensed, full service Canadian pharmacy which quickly delivers generic, compounded, refrigerated, controlled, and brand-name medications across Canada for fees that are, generally, far lower than your local pharmacy.  Delivery is totally free and fast. It also offers several premium services, such as dose packs, virtual care, and patient support programs (which can make your medication free) at no cost to you, along with various retail products you might find at your local pharmacy.

With new limits on dispensing fees, dispensing frequency, generic medications, and prior authorization, large health plans often partner with pharmacies to offer plan members tailored services at a lower cost.  PIPSC has identified Mednow as one of the most competitive pharmacy partners for our members and members of the PSHCP.

Mednow is partnered with PIPSC through our ServicePlus program and is available to all PIPSC members regardless of PSHCP membership.  Through this partnership, PIPSC members will benefit from a ten percent rebate on the cost of their prescription drugs.  This effective cuts your out-of-pocket cost in half (from twenty to ten percent). All PIPSC members are eligible to join the ServicePlus program for free, no strings attached.

Due to government regulations, further note that this rebate is not provided on medications shipped to Quebec and that Mednow must charge all customers (outside Quebec) the same $8.99 dispensing fee of which 99 cents will not be covered by your health plan.

Go to ServicePlus and select Mednow from the list of partners.  From here, you can signup using our Mednow group code to take advantage of this deal.

PIPSC has compared Mednow pricing for a range of medications against various Canadian low-cost pharmacies.  Mednow was consistently cheaper than even the most affordable low-cost pharmacies. Compared to a typical retail pharmacy, Mednow’s drug prices are generally twenty percent cheaper or more. What is more, Mednow is cutting your out-of-pocket expense in half by offering PIPSC members preferred pricing on medications.

Yes and yes.  Mednow ships nearly every type of medication, including special-handling, controlled, temperature-sensitive, and specialty drugs to nearly every region in Canada from coast to coast to coast.

A Prior Authorization system will be implemented for the PSHCP effective July 1, 2023.

A Prior Authorization system is a process administered by the plan administrator where an extremely small number of very high-cost drugs need to be pre-approved before they are reimbursed under the PSHCP. It is an evidence-based program that will be supported by medical professionals at Canada Life who will review the request in a very short window to ensure you are getting the most medically appropriate, cost-effective medication.  This program has been designed to make things easy as possible for plan members with simple paperwork and a fast turnaround time.

Permanent legacy protections will be granted for members who were on affected prescribed drugs before July 1, 2023 which are listed on Canada Life’s Prior Authorization formulary. This formulary is currently being developed and will be published at a later date.

There are extremely minimal changes to the plan formulary (what medications are covered); however, a prior authorization program for a very narrow range of high cost drugs is being introduced. This program makes sure plan members are getting the more clinically appropriate medication at the lowest cost. Research shows that the newest, most heavily marketed drug is often prescribed when an older or lower cost drug may be more clinically appropriate. The prior authorization program uses independent medical evidence to ensure plan members are getting the drug that is most suited to their circumstances, be it a cheaper or a more expensive medication.  The plan administrator has no financial incentive to choose a cheaper or more expensive drug – decisions are made entirely on evidence based treatment protocols and in a very timely manner.

A biosimilar is a biologic drug (medications derived from or designed to mimic biological sources) that is very similar to a biologic drug that was already authorized for sale. It’s a bit like the difference between generic and name brand drugs, but for a different, more complex class of medications. Independent research has shown that biosimilars work in nearly every instance without any additional adverse reactions.

Canada Life will issue a biosimilar switching program which will require plan members to substitute a biologic drug for the biosimilar when medical evidence supports such substitution. Switching programs are developed in collaboration with experts in oncology, gastroenterology, dermatology, and other medical specialisations. These substitution programs are becoming an industry standard and have been adopted by most provincial drug plans. There will also be an exception process to allow for coverage of biologics when the biosimilar cannot be used, as well as a grace period to allow members time to switch over.

The PSHCP will implement a change to compound drug eligibility following a 180-day legacy period commencing July 1, 2023.

After the legacy period, compound drugs will require one active ingredient with a Drug Identification Number (DIN) that is covered under the PSHCP, to be reimbursed. This change closes a costly loophole in the plan allowing coverage for certain products of dubious medical necessity which were reimbursed by the plan for the sole reason that they were compounded by a pharmacist.

During the legacy period, compounded drugs without a DIN will generally continue to be eligible for coverage.

Yes, Canada Life will accept prescriptions written by a Nurse Practitioner for medical supplies, medications, and treatments provided they are allowed to issue such prescriptions by their provincial order.

Wig coverage has increased from $1,000 to $1,500$ ($1,500 every 5 years). Canada Life’s wig program differs slightly from SunLife’s in that a broader range of medical conditions/symptoms will be eligible for wig coverage.

Orthopaedic shoes coverage has increased from $150 to $250 per calendar year. They must be prescribed by a physician, podiatrist, or nurse practitioner.

Yes.  Coverage is still reimbursed at 80%, but there are new limits:

• Insulin jet injector coverage has increased from $760 to $1,000.  $1,000 every 3 years
• Continuous Glucose Monitor supplies $3,000 per calendar year for Type I diabetics only
• Diabetic monitors are covered at $700 per 5 years. Eligible with or without insulin pump

Diabetic testing supplies $3,000 per calendar year

Coverage will be set at $200 per year with a prescription. All medically appropriate conditions will be covered.

Yes. The plan will allow for claims for a new wheelchair within the five-year limit when a 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 five-year period.

The wheelchair and walkers must be manufactured specifically for medical use, approved by the Administrator for cost effectiveness and clinical value and designated as medically necessary.

The benefit will be increased to $1500 from $1000. There will be an additional $200 annual battery allowance.

Medical grade injectable lubricants for joint and arthritic pain will be covered by the plan for up to $600 per year with a prescription.

Prescription eyeglasses/contact lens coverage has increased from $275 to $400 every two years starting on the odd year. Laser eye surgery coverage has increased to $2000 from $1000 per lifetime.

Members may wish to consider purchasing their contact lenses and glasses through an online retailer which, generally, have the same brands as retail stores for significantly lower prices. Contact lens prices may be as much as seventy percent cheaper than retail outlets. Most online retailers offer the same products and services as typical retail outlets; however, in some rare cases, specialty products will not be available. Members may wish to consider low-cost optical stores such as those offered by warehouse clubs (membership usually not required for optical purchases). Serviceplus has an online eyeglass and contact lens partner, Clearly Contacts, that offers preferential rates to members.

Yes, the benefit increased from $500,000 to $1 million per trip. Coverage remains for the first forty days of any trip; however, travel time will exclude days spent on official travel status.

Benefits for family assistance while travelling have also increased.

As retired PSHCP members pay fifty percent of the plan premiums, the PSHCP has a special provision for low-income retirees to assist with their premiums. Under the updated plan, this provision will be renewed to cover low income seniors who retire between April 1st 2015 and March 31st 2025. PSHCP retiree members who are in receipt of the Guaranteed Income Supplement may be eligible for this provision. Additional information on the renewal of this program will be published on the PSHCP website at a later time.

Yes, benefits have increased to $2000 from $1000. If you already claimed the previous $1,000 lifetime maximum, you may claim an additional $1,000 for expenses incurred on or after July 1, 2023.

Generally, it is not allowed to bill a workplace health plan for treatment to address a workplace injury. Occupational illnesses and accidents are fully insured (without limits) by way of the provincial workers’ compensation schemes. This is why it is so important for injured workers to file claims so that they can hold the employer accountable for unsafe working environments and get the employer-paid treatment they need to address their occupational injury

Because we do not negotiate this plan, we base benefits on benchmarked comparator plans – none of which offer cannabis coverage at the moment. Furthermore, there remains a limited amount of good, medically-accepted data around dosing guidelines. While this was an item we spoke about extensively during plan review, we do not believe it was feasible to obtain its inclusion in this round of plan review.

PSHCP Appeals Process:  https://www.pshcp.ca/appeals/

Please contact the PSHCP Call Centre at 1-888-757-7427 (toll-free from anywhere in North America) or 613-247-5100 (in the National Capital Region).  Not that the call centre cannot provide information on the updated plan at this time.

The dental plan is independent of the health plan.  A review of the dental plan is expected to commence in 2023.

Information about the improvements and changes can be found at :

https://www.canada.ca/en/treasury-board-secretariat/services/benefit-plans/health-care-plan/information-notices/improvements-changes-public-service-health-care-plan.html?utm_source=ens-oct-22&utm_medium=email&utm_campaign=tbs-sct-ens-21-22&utm_content=improvements-pshcp-en

PSHCP Bulletin 44: https://pshcp.ca/articles/pshcp-bulletin-44/