With the new PSHCP deal set to come into force in July, we’ve collected the answers to the questions we hear the most.
About the PSHCP
- What does the PSHCP cover?
- What is included in the PSHCP renewal?
- What is Federal Retirees’ role?
- What is the Treasury Board Secretariat's role?
- What about PDSP?
- Will I get a new Canada Life insurance card?
- Do I have to present my new card to my pharmacist?
- When and how can I contact Canada Life?
Plan benefits and coverage enhancements
- What are the new coverage amounts?
- Do my coverage amounts reset when Canada Life takes over?
- What if I don’t use vision care or massage services during the first part of the year?
- Will the coverage enhancements increase my costs?
- What has changed with physiotherapy coverage?
Drug coverage changes
- What has changed with the PSHCP’s drug coverage?
- What is generic substitution?
- Can I still get brand name drugs?
- Is it dangerous to switch to generic?
- What’s changing with dispensing fees?
- How much will I be reimbursed for my dispensing fee?
- What is the dispensing frequency limit for maintenance medications?
- Does Federal Retirees have a preferred partnership with a pharmacy?
- What is prior authorization and when will it begin?
- Do I have to change my biologic/biosimilar medication?
- Is my cancer drug still covered?
Plan renewal process and other questions
- Are the changes for this renewal final?
- When will the PSHCP be reviewed again?
- The new plan doesn’t meet my needs. How were the priorities determined?
About the PSHCP
The Public Service Health Care Plan (PSHCP) is one of the largest private health-care plans in Canada. It covers more than 1.4 million members, including retired federal public servants and federally appointed judges as well as veterans of the Canadian Armed Forces and RCMP.
The PSHCP is a voluntary plan that reimburses plan members for eligible health-care expenses after plan members have taken advantage of their provincial/territorial health-care coverage.
PSHCP coverage includes things like prescription drugs, medical devices and equipment as well as services from providers like massage and physiotherapists. Coverage is subject to eligible charges, maximum amounts and co-payments. The plan also covers a basic level of out-of-province emergency medical expenses for the first forty days of a trip, and the Federal Retirees MEDOC travel insurance also coordinates with the PSHCP.
To find out more about what the PSHCP currently covers, consult the current plan directive or contact the current plan administrator, Sun Life, by telephone, online or by mail:
- 1-888-757-7427 (toll-free within North America)
- 613-247-5100 (National Capital Region)
- Sunlife Assurance Company of Canada, PO Box 6192, STN CV, Montreal, QC, H3C 4R2
After July 1, 2023, you will need to contact Canada Life instead of Sun Life. Canada Life can be reached at:
- 1-855-415-4414 (toll-free)
What is included in the PSHCP renewal?
To learn more about enhancements and changes coming to the PSHCP in 2023, check out our PSHCP newsfeed on the plan and its recent renewal, follow Federal Retirees on social media and make sure you’re subscribed to our newsletter.
A new PSHCP plan directive (or plan document outlining coverage) will be available over the coming months.
What is the role of the National Association of Federal Retirees in the PSHCP?
The PSHCP partners committee oversees the PSHCP. The partners committee includes three employer representatives, three representatives from the federal public sector unions and one pensioner representative from the National Association of Federal Retirees. Currently the pensioner representative is the Association’s president, Roy Goodall. During negotiations, the partners committee puts forward a joint recommendation to the Treasury Board on updates to the PSHCP.
Federal Retirees also helps members navigate their benefits coverage and tracks concerns with the plan, which the pensioner representative raises with the partners committee.
What is the role of the Treasury Board Secretariat in the PSHCP?
The Treasury Board of Canada Secretariat, as the employer, is the sponsor of the PSHCP. The PSHCP Administration Authority provides monitoring and oversight of regular operations of the PSHCP, including support in dealing with appeals. Together, it is also responsible for ensuring a smooth implementation of the PSCHP.
Finally, the Treasury Board is a committee of the federal cabinet which approves government financial and budgetary policies and decisions, including for pensions and benefits. For more information, visit the Treasury Board of Canada Secretariat online.
What about the dental plan or PDSP?
The Pensioners Dental Services Plan (PDSP) is separate from the PSHCP. There are currently no changes to report for the PDSP. The PDSP is still being administered by Sun Life.
In 2023, Federal Retirees will survey its members on their dental coverage needs. The Association plans to pursue improvements to the PDSP, so be sure to follow Federal Retirees on social media and make sure you’re subscribed to our newsletter to keep up to date.
If you have questions about the PDSP, please contact Sun Life Assurance Company of Canada by telephone or mail, or visit the PDSP online:
- 1-888-757-7427 (toll-free within North America)
- 613-247-5100 (National Capital Region)
- Sun Life Assurance Company of Canada, PO Box 9805, CSC-T, Ottawa, Ontario, KIG 6M6
When the plan administrator changes on July 1, 2023, will I get a new Canada Life insurance card, or can I keep and use my old Sunlife card?
New Canada Life member cards will be issued in spring 2023, once enrolment is completed. The card will indicate a member’s new Canada Life group plan number, but members will keep their current certificate number.
Members completing enrolment online will be able to download their new benefit card electronically according to instructions that will be provided by Canada Life.
Members who complete enrolment using paper forms will receive their card by mail once their information has been validated by Canada Life.
Members will be able to sign up with Canada Life’s plan member services website once they have completed positive enrolment in spring 2023. However, plan members’ coverage information, including benefit limits and balances, will only be available on the Canada Life website as of July 1, 2023.
You can avoid disruptions to your PSHCP coverage by keeping your information updated with Sun Life and, when the time comes, with Canada Life. Ensure a seamless transition by monitoring your email inbox and mailbox for news and updates from Sun Life and Canada Life.
Ifyou have any concerns that a request from the Canadian government, Sun Life or Canada Life is fraudulent, never hesitate to reach out to the issuing organization or department. For more information about spotting scams and reporting fraud, refer to resources from the Canadian Anti-Fraud Centre.
Do I have to present my new card to my pharmacist?
Yes, you will need to present your new Canada Life card to your pharmacist to update your information. In the meantime, remember to use your Sun Life card until June 30, 2023. Your Canada Life coverage takes effect on July 1, 2023.
How and when can I get in touch with someone from Canada Life about plan coverage?
Canada Life should open its call centre by April 2023. The telephone number will be 1-855-415-4414 (toll-free) and it will be open from Monday to Friday between 8 a.m. and 5 p.m. Eastern Time. For more information, visit canadalife.com/pshcp to connect with Canada Life online.
You should consult the current PSHCP Plan Directive for information about what’s currently covered. A new plan directive will be available soon.
Plan benefits and coverage enhancements
What are the new coverage amounts?
New coverage amounts take effect July 1, 2023. and a list of them can be found on our website. Additional details on specific benefits will be available over the coming months.
Do my coverage amounts reset when Canada Life takes over?
No. For example, consider massage therapy. Currently, plan members may claim up to $300 in eligible massage therapy expenses, reimbursed at 80 per cent. Under the renewed PSHCP, massage therapy will be covered up to $500, reimbursed at 80 per cent. Plan members will be eligible to claim $300 up to June 30, 2023 and will have access to the additional $200 after July 1, 2023. 2024 will be the first full calendar year with the new coverage amounts.
The PSHCP Administration Authority has confirmed that unused annual allocations remain available until the end of the calendar year (importantly, some benefits are subject to different timelines for eligibility such as a 2-year benefit period for vision). Consult the Treasury Board Secretariat’s update on PSHCP changes for more examples of coverage amounts during 2023.
If I don’t use the vision care or massage services during the first part of the year, can I transfer this amount during the second part of the year?
If you don’t claim any eligible expenses from January to June 2023, the full amount you will be eligible to claim during 2023 will not exceed the new coverage amounts.
For example, consider massage therapy. Currently, plan members may claim up to $300 in eligible massage therapy expenses, reimbursed at 80 per cent. Under the renewed PSHCP, massage therapy will be covered up to $500, reimbursed at 80 per cent.
Plan members will be eligible to claim $300 up to June 30, 2023, and will have access to the additional $200 after July 1, 2023. Conversely, a plan member who does not claim any eligible massage therapy until after July 2023 will still only be able to claim up to $500, reimbursed at 80 per cent, for the 2023 calendar year. Refer to the Treasury Board Secretariat’s update on PSHCP changes for additional examples of coverage amounts during 2023.
Will the coverage enhancements increase my costs for health-care coverage?
There are two aspects to consider when it comes to potential cost increases for pensioners. First, pensioner contributions (or premiums) are based on how much pensioners claim against the plan in the year preceding. If those costs increase in any given year, then so do pensioners’ contribution rates the following year.
However, it’s important to remember that measures to help contain costs have been agreed to and will be implemented.
Because plan changes will only take effect in July 2023, any cost impacts from higher usage or claim amounts that are the result of benefit enhancements and cost containment measures will only be partially reflected when pensioner contribution rates or premiums are adjusted in April 2024. The first full year of the renewed plan will be in 2024.
We’ll be monitoring the plan performance closely, and the PSHCP partners committee will reconvene to review the effectiveness of plan changes in 2025. We’ll continue to focus on ensuring members have high-quality health-care coverage and work to minimize cost impacts for pensioners.
What has changed with physiotherapy coverage?
The PSHCP partners committee approached the physiotherapy benefit by benchmarking against comparable plans, considering plan members’ needs, and ensuring the plan remains sustainable.
The current plan offers physiotherapy as an unlimited benefit (the plan covers up to $500 with an 80 percent copayment; members must pay out of pocket for expenses between $500 and $1,000; and coverage is reinstated after that point).
No comparable plans offered such an extensive benefit. In order to protect the plans integrity and sustainability, some changes needed to be made — and that included physiotherapy.
Under the updated plan, the member-paid corridor (for eligible physiotherapy expenses between $500 and $1,000) will be removed. This means that members will receive 80 percent reimbursement on the first $1,500 of physiotherapy they claim each year, which this is an improvement for most plan members. However, we understand that a greater benefit for more members comes at the expense of more comprehensive coverage for those with chronic conditions.
Following requests from some of our members to continue with current levels of PSHCP physiotherapy coverage, we are asking the Treasury Board president and partners committee to review the needs of members who have relied heavily on physiotherapy with the PSHCP. The outcome of this request is still pending.
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 and enable members to take a multidisciplinary approach, 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 (previously, acupuncture was capped at $300 and had to be performed by a physician)
- Osteopath at $500 per calendar year
The administrative processes around the introduction of the annual maximum for physiotherapy are still being worked out, including what amounts a plan member will have access to during 2023. Once more details are available, they will be communicated to plan members.
The National Association of Federal Retirees would like to recognize the Professional Institute of the Public Service of Canada (PIPSC) for its support in answering member questions about physiotherapy coverage. To learn more about PIPSC, and its role in the PSHCP, visit PIPSC online.
Drug coverage changes
What has changed with the PSHCP’s drug coverage?
Currently, the plan covers almost every drug authorized 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 carried by the plan. In Canada, while drugs are tested extensively for safety, side effects and usage, there is generally little to no regulation on the cost or relative effectiveness of prescription medications.
This has led to significant increases in drug spending that offer little or no benefit to plan members. Methods of addressing these cost pressures have evolved since the PSHCP was last updated, which is reflected in some of the plan’s new rules.
The PSHCP will have:
- Mandatory generic substitution or reimbursement
- Limits on dispensing fees and their frequency
- Prior authorization for specialty medications
In addition, compound drugs will require at least one ingredient to have a drug identification number (DIN) to be eligible for reimbursement under the PSHCP.
Finally, the out-of-pocket maximum for catastrophic drug coverage, intended to protect those with exceptionally high drug costs, will increase moderately, from $3,000 to $3,500. Once a plan member exceeds the out-of-pocket maximum for eligible prescription drugs in any calendar year, reimbursement of additional expenses incurred in that year increases from 80 per cent to 100 per cent.
Generic substitution means that all prescription drugs covered by the PSHCP will be reimbursed at 80 per cent of the cost of the lowest-priced alternative generic drug unless an exception is completed by the prescriber and approved by Canada Life. There will be a 180-day period starting July 1, 2023, for plan members to make this transition if they are taking brand-name drugs.
Can I still get brand name drugs?
Yes, but only if it is medically necessary.
The current plan will only cover the cost of a brand name medication when the prescription states no substitutions are permitted. After July 1, 2023, it will become necessary to justify the reason, such as an allergy to an ingredient.
Currently, the plan has an unusually high number of claims requiring no substitutions when weighed against medical evidence. By introducing mandatory generic substitution, members will still have access to brand-name drug coverage when it is necessary.
For the first 180 days of the updated plan, starting July 1, 2023, previously covered prescribed brand-name drugs will still be reimbursed at 80 per cent of their cost.
After this legacy period, all prescription drugs covered under the PSHCP will be reimbursed at 80 per cent of the cost of the lowest-priced alternative generic drug unless an exception is completed by the prescriber, sent to Canada Life and approved.
The process for submitting an exception for approval will be provided as we get closer to July 1, 2023.
If you still wish to use a brand-name medication but do not want to complete the required form or have no medical reason for the preference, you can still choose to fill the brand name, but you will have to cover the difference in cost.
I’m worried about switching my medication to a generic because I’ve heard generics aren’t as effective or that the switch may cause health-related problems for me.
The belief that generic drugs are less effective than brand-name drugs is inaccurate. In rare cases the non-active ingredients of generic medications, such as binders, fillers and dyes can pose problems for some individuals. However, generic drugs are equivalent to brand name drugs; they must be the same in terms dosage of the active ingredient, safety, effectiveness, strength, stability, quality and how they’re taken. This along with adverse reactions to generic medications are strictly watched by Health Canada, where some of our own members work or have worked. Currently, 70 per cent of PSHCP members who are retired already use generic medications.
However, when it comes to transitioning from a brand-name drug to a generic medication, be sure to speak with your health-care providers as soon as possible. This will help them to understand your benefits coverage limitations and timelines and to file any paperwork that will be needed if you are medically required to remain on a brand-name drug. Make sure you have the input and monitoring of your prescribing health-care provider before changing anything about your medications, including switching to generic drugs.
What’s changing with dispensing fees?
Two aspects of how dispensing fees are reimbursed by the PSHCP will change: the amount the PSHCP reimburses for dispensing fees and the number of dispensing fees covered per year for maintenance medication.
How much will I be reimbursed for my dispensing fee?
Starting July 1, 2023, the PSHCP will reimburse up to $8 of the pharmacy dispensing fee. This is based on average dispensing fees in Canada. This cap does not apply to biologic or compound drugs, which may require special handling and dispensing, nor will it apply to drugs that are controlled substances or those with storage considerations.
Plan members should choose their pharmacy wisely to ensure they can maximize the covered amount. If your drugstore charges more than what the PSHCP covers, you will be required to pay the difference.
What is the dispensing frequency limit for maintenance medications?
Starting July 1, 2023, maintenance drugs — usually those used to manage things like blood pressure, cholesterol, stomach hyperacidity and some mental health concerns — will need to be filled in three-month intervals. Plan members will be eligible to claim up to five maintenance drug dispensing instances per year. This will roughly correspond to filling prescriptions along a 90 to 100 day interval.
Otherwise, the PSHCP and plan members would be paying dispensing fees and drug mark-up costs unnecessarily, which has a financial impact on the plan and on pensioners’ contribution rates.
If plan members wish to get their maintenance drugs in shorter intervals, they can still do so, but will be limited to five dispensing fee instances per year for maintenance drugs.
This provision does not apply in cases where the co-payment for a three-month supply will be more than $100, nor will it apply to drugs that are defined as controlled substances, medications with special storage requirements (such as those requiring deep-freeze temperatures) or where provincial/territorial pharmacy regulations make it impossible to implement. An exception process will also be available for plan members who require blister packaging, which may have to be dispensed more frequently than every 90 to 100 days.
Does Federal Retirees have a preferred partnership with a pharmacy so that we have lower refill fees?
Federal Retirees currently does not have a preferred pharmacy partnership for reduced prescription medication refill fees, but this is something the PSHCP partners committee has agreed to explore so that members can make the most of the covered dispensing fee amount. We encourage members to consider their financial and health-care needs and find a pharmacy that meets those needs.
Specialty medications and prior authorization
What is prior authorization and when will it begin?
Prior authorization programs are commonly used by health benefits and insurance plans to help ensure plan members are being optimally treated with clinically and cost-effective treatments when it comes to specialty drugs. Specialty drugs include biologics and biosimilars, which can be extremely costly.
Prior authorization is a process administered by the plan administrator (in this case, Canada Life) 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.
The prior authorization program uses independent medical evidence to ensure plan members are getting the drug that is most suited to their circumstances, and decisions are made on evidence-based treatment protocols and in a very timely manner.
There will also be an appeal process for prior authorization concerns, and details on that will be communicated to plan members when they are available.
Prior authorization will begin on July 1, 2023. The list or formulary of affected drugs is in development and will be published soon.
I am on a biologic or biosimilar now, or may be on one in the future. What will happen to my coverage? Do I have to change my biologic/biosimilar medication?
Up to July 1, 2023, if you are on any of the prescription drugs that are part of the prior authorization formulary (or list), you will not have to go through the prior authorization process — your coverage will continue.
However, if a biosimilar is available, members may be required to switch their biologic drug to a biosimilar after July 1, 2023. Affected members will be contacted by Canada Life. (Biosimilar drugs are comparable, cost-effective versions of biologic drugs, and are proven to be as safe and effective as biologics.)
If you will be prescribed a biologic drug that is on the prior authorization formulary for the first time after July 1, 2023, you will be required to undergo the prior authorization process to have your medication pre-approved for reimbursement under the PSHCP. Your prescribing health-care provider will be required to complete a form(s) and communicate with Canada Life.
Switching programs are developed in collaboration with medical expertise. 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 plan members time to switch over.
Exceptions will be considered and based on medical evidence. Your prescribing health-care provider will need to complete a form, providing medical evidence that confirms the reason for the exception, and submit it to Canada Life for review.
There will be an appeals process for prior authorization concerns, and details on that will be communicated to plan members.
Is my cancer drug still covered?
The PSHCP will see minimal changes to the formulary (or list) of drugs covered. While prior authorization (or requirement for pre-approval) is being established, it should be noted that this will affect a narrow range of high-cost drugs, usually biologics or specialty drugs. The formulary of affected drugs is being developed and will be published soon.
Plan renewal process and other questions
Are the changes for this renewal final?
Yes, the changes that have been announced are final. They have been approved by the PSHCP partners committee and by the Treasury Board.
When will the PSHCP be reviewed again?
This PSHCP deal lasts four years, until 2027, with a mid-point review. Federal Retirees will ensure the plan is thoroughly reviewed within that timeline. If there are coverage enhancements or other changes, you’d like to see in the next round of PSHCP renewal, please let us know!
Association members will also have a chance to share their thoughts on further PSHCP improvements when we circulate a survey in advance of the mid-point review.
I am frustrated the new plan doesn’t meet my needs. Who made the decision about priorities? How were the priorities determined?
We are sorry to learn that the plan is not what you would have liked. Priorities for the PSCHP renewal were determined following a 2017 Federal Retirees survey of nearly 19,000 individuals, which consulted members on their needs and experiences with the plan. More than 8,500 responses were received. When asked for their top priorities for the PSHCP renewal, members said that vision care enhancements, unrestricted access to physiotherapy and massage therapy, better paramedical and hearing aid coverage, improvements to hospital coverage and emergency travel benefit enhancements were most important to them. We are proud that the deal we have delivered meets each of those needs.
Several extensive studies and reports on the PSHCP were conducted to better understand gaps in the plan as well as cost-saving opportunities. These studies were conducted starting in 2016, and updated in 2019, to ensure we, together with the PSHCP partners committee, had the best data possible when negotiating the plan.