Update: Improvements and changes to the Public Service Health Care Plan­­­

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 respond 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 a detailed overview of the entire plan, visit the PSHCP summary page.

Increased reimbursement

The maximum reimbursement amounts for certain products and services have increased. The increased amounts will only be applicable to items or services acquired on or after July 1, 2023. For example, the annual benefit for massage therapy services has increased from $300 to $500. If a plan member submitted claims totaling $300 for services received before July 1, 2023, they will be eligible to claim an additional $200 for any services received after that date.

Improvements to your benefits

• Medical practitioners Reimbursed at 80%

Acupuncturist

• $500 per calendar year
• No prescription required
• Services can now be provided by a registered acupuncturist

Electrologist

• $1,200 per calendar year
• A prescription is required unless the plan participant is undergoing treatment related to gender-affirmation care.
• Reimbursement is no longer capped at $20 per visit

Registered Dietitian

• $300 per calendar year
• New benefit
  • No prescription required

  Lactation consultant

  • $300 per calendar year
  • New benefit
    • No prescription required
    • Services covered by the province or territory of residence must be exhausted first

    Massage therapist

    • $500 per calendar year (increased from $300)
    • Prescription not required

    Naturopath

    • $500 per calendar year (increased from $300)
    • Prescription not required

    Nurse practitioner

    • 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

    Nursing services

    • $20,000 per calendar year (Increased from $15,000)
    • Must be medically necessary and provided by a licensed nurse in the personal residence of the covered member

    Psychological services (Psychologist)

    • $5,000 per calendar year (increased from $2,000)
    • Prescription not required
    • Mental health services can now be provided by the following providers:
      • psychologists
      • social workers
      • psychotherapists
      • counsellors, as deemed qualified by the plan administrator based on provincial/ territorial accreditation

      Physiotherapist

      • $1,500 per calendar year
      • 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

      Occupational therapist

      • $300 per calendar year
      • New benefit
        • No prescription required

        Osteopath

        • $500 per calendar year (increased from $300)
          • Prescription not required

          Podiatrist or chiropodist

          • $500 per calendar year (increased from $300)
          • 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

          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

          Laser eye surgery

          • $2,000 per lifetime (increased from $1,000)
          • 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

          Prescription eyeglasses, contact lenses (purchase and repairs)

          • $400 every 2 years starting on the odd year (increased from $275)
          • Starting January 1, 2025, prescription eyeglasses or contact lenses can be claimed up to $400 every 2 years

          Smoking cessation drugs

          • $2,000 per lifetime (increased from $1,000)
          • 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

          Continuous Glucose Monitor supplies

          • $3,000 per calendar year
          • New benefit for people with Type I diabetes only

          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

              Diabetic testing supplies

              • $3,000 per calendar year
              • Eligible for all diabetic types
              • Continuous Glucose Monitor supplies are not covered under the diabetic testing supplies benefit

              Insulin jet injector

              • $1,000 every 3 years (increased from $760)

              Aerotherapeutic supplies

              • $500 per calendar year (increased from $300)
              • Devices, such as CPAP or BiPAP are not covered under the “supplies” benefit. Supplies may include repairs

              Hearing aids

              • $1,500 every 5 years (increased from $1,000)
              • 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

              Batteries for hearing aids

              • New benefit
                • $200 per calendar year
                • Batteries continue to be covered under an initial hearing aid purchase
                • This new benefit provides coverage for replacement hearing aid batteries

                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

                    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

                      Orthopedic shoes

                      • $250 per calendar year (increased from $150)
                        • Must be prescribed by a physician/nurse practitioner or podiatrist

                        Walkers and wheelchairs

                        • 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)

                          Wigs

                          • $1,500 every 5 years (increased from $1,000)
                            • 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.

                            Level I

                            • $90 per day (increased from $60)

                            Level II

                            • $170 per day (increased from $140)

                            Level III

                            • $250 per day (increased from $220)

                            Emergency benefit while travelling

                            • $1 million per trip (increased from $500,000)
                            • Out-of-province coverage for 40 consecutive days, excluding any time out of the province for business on official travel status

                            Family Assistance Benefits

                            • $5,000 per travel emergency (increased from $2,500)
                            • Increased meals and accommodations benefit from $150 to $200 per day

                            Pensioner relief provision

                            • Relief provision extended to include members who retire after April 1, 2015, extended until March 31, 2025, provided they meet the following criteria:
                              • are in receipt of a Guaranteed Income Supplement (GIS) benefit or
                              • have a net or combined net income lower than the GIS thresholds

                              Injectable lubricants for joint pain and arthritis

                              • New benefit
                                • $600 per calendar year
                                • Prescription required
                                • Not eligible for cosmetic purposes

                                Gender Affirmation

                                • New benefit
                                  • $75,000 per lifetime
                                  • For certain gender-affirming care 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
                                    • be 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-Affirming Care Application Form to be completed by both the covered person and the attending physician/nurse practitioner and submitted to the plan administrator for review

                                    Changes to your plan

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                                    • Prescription Drugs

                                    Mandatory Generic Drug Substitution

                                    • The PSHCP will implement Mandatory Generic Drug Substitution following a legacy period ending December 31, 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

                                        Prior Authorization and 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.
                                          • 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
                                            • 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

                                              Compound Drugs

                                              • The PSHCP will implement a change to compound drug eligibility following a legacy period ending December 31, 2023.
                                                • New compound drug prescriptions will require at least 1 active ingredient to have a Drug Identification Number (DIN) that is covered under the PSHCP

                                                Catastrophic Drug Coverage

                                                • 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%

                                                  Frequency Limits

                                                  • Pharmacist dispensing fees will be reimbursed up to a maximum of 5 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)
                                                    • when the prescribed drug’s 3-month supply co-pay is more than $100

                                                    Fee Caps

                                                    • 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. Should there be any discrepancy between this information in this Information Notice and that contained in the PSHCP Directive, the PSHCP Directive applies.

                                                      Plan members are encouraged to keep medical receipts and records for at least 1 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.