Update on the Public Service Health Care Plan

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.

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:

1. Switch to the lowest-cost alternative generic drug and be covered for 80% of the cost of that drug
2. 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
3. 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

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.

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.).

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

• 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.