Public Service Health Care Plan summary

This is a summary of the Public Service Health Care Plan (PSHCP), which is offered to eligible employees and retirees of the public service(including the Royal Canadian Mounted Police and the Canadian Armed Forces) and participating employers, and members of certain designated groups. It does not contain all details or describe all limits, restrictions or exclusions. For additional information, please refer to the PSHCP Directive or the Federal PSHCP Administration Authority website; or contact your departmental Compensation services, the Public Service Pay Centre, pension office, or the Government of Canada Pension Centre. The PSHCP is designed to supplement your provincial/territorial health insurance plan for reasonable and customary eligible expenses. This is referred to as Supplementary Coverage. If you are deployed or posted outside of Canada by your employer or live outside of Canada as a retiree and are no longer eligible under a provincial/territorial health insurance plan, please refer to the PSHCP Directive or the Federal PSHCP Administration Authority website for a description of Comprehensive Coverage. The following information is for members with Supplementary Coverage.

Eligibility

• Optional coverage for:
  • Full-time and part-time employees and employees appointed for more than 6 months or who have completed 6 months of continuous employment
  • Retired members with at least six years of pensionable service (some exceptions apply, please see the Plan Directive or PSHCP Member Booklet for more information) in receipt of an ongoing recognized pension
  • Eligible spouses or common-law partners and dependant children of plan members, including survivors

  For definitions of terms used, please consult the PSHCP Directive definitions page.

  Note: Provisions for members of the RCMP and Canadian Regular and Reserve Forces

  Application and Effective Date

  Active Member

  To apply, you must complete and submit a Public Service Health Care Plan (PSHCP) online application on the Compensation Web Applications (CWA). Alternatively, a paper PSHCP Employee Application form (PDF, 95 KB) can be submitted to your departmental Compensation services or the Public Service Pay Centre.

  • If your completed application is received within 60 days from the date you become eligible for coverage, your PSHCP coverage will take effect on the first day of the month following receipt of your application.
  • If your completed application is received more than 60 days after the date you become eligible for coverage, your PSHCP coverage will take effect on the first day of the fourth month following receipt of your application.

  Retired Member

  To apply, you must complete and submit a paper Public Service Health Care Plan (PSHCP) Pensioner Application Form (PDF, 91 KB) to the Pension Centre. If you were a member of the PSHCP as an active member, you may choose to continue your PSHCP coverage by accepting to pay the monthly contributions in your retirement package.

  • If you were not a member of the PSHCP before retirement, your PSHCP coverage will take effect the first day of the fourth month after your completed application is received. Some exceptions apply. Consult the PSHCP Directive for more information.

  Positive Enrolment

  Once your application is approved, you will be issued a certificate number which you will need to complete Positive Enrolment with the plan administrator, Canada Life.

  This involves providing information to Canada Life about yourself, your spouse/common-law partner and each eligible dependant child, including full name, address, gender and age, and whether you or any of your dependants have coverage under another group health care plan. To receive your Public Service Health Care Plan (PSHCP) benefit card and have your claims paid under the PSHCP, you must complete positive enrolment. If you do not, your claims will not be paid.

  If you were a PSHCP member before retirement or experienced any life changes, you will need to update your positive enrolment information.

  Reimbursement Percentage

  • 80% of eligible expenses or of stated maximums, if any

  Eligible Expenses

  Extended Health Provision

  Prescription Drugs (Reimbursed at 80%):

  • Drugs that legally require a prescription
  • Certain Life-Sustaining Drugs
  • Smoking cessation aids: Lifetime maximum $2,000
  • Erectile dysfunction drugs: Maximum $500 per calendar year
  • Mandatory Generic Drug Substitution: following a legacy period ending December 31, 2023
    • Until December 31, 2023, prescribed brand name drugs will still be reimbursed at 80% of their cost for those with existing prescriptions, if processed electronically at the pharmacy using the PSHCP Benefit Card
    • Starting July 1, 2023, new prescriptions will be subject to mandatory generic drug substitution
    • 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
      • Exception: If the generic version of the drug cannot be prescribed, due to a medical reason, the brand name drug may still be reimbursed at 80%.
      • This program is administered by the plan administrator where certain drugs need to be pre-approved before they are reimbursed under the PSHCP
      • Until July 1, 2023, if a member is on any of the prescription drugs that are part of the Prior Authorization program, they will not be required to go through the Prior Authorization process to continue receiving that prescription
      • Starting July 1, 2023, 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
      • Until December 31, 2025, if a plan member is on a biologic drug where there is a biosimilar available, plan members may be contacted with further details on the transition to biosimilars
      • For new prescriptions, when available, biosimilars will be chosen
        • Exceptions will be considered based on medical evidence

        Note: Provisions when out-of-pocket drug expenses exceed $3,500 per calendar year

        Vision Care (Reimbursed at 80%)

        • Eye examination: 1 every 2 calendar years starting odd years
        • Eyeglasses or contact lenses: Maximum $400 every 2 calendar years commencing odd years
        • Elective laser eye surgery: Lifetime maximum $2,000

        Medical Practitioners (Reimbursed at 80%)

        • Physiotherapist: Maximum $1,500 per calendar year
        • Psychological services: Maximum $5,000 per calendar year
        • Massage Therapist, Acupuncturist, Chiropractor, Osteopath, Naturopath or Podiatrist/Chiropodist: Maximum $500 per calendar year per type of practitioner
        • Speech-Language Pathologist, or Audiologist: The services of a speech language pathologist or audiologist can be claimed to a combined maximum of $750 per calendar year
        • Nursing services: Maximum $20,000 per calendar year
        • Registered Dietitian, Occupational Therapist, Lactation Consultant: Maximum $300 per calendar year per type of practitioner.
        • Electrologist: Maximum $1,200 per calendar year

        Dental Treatment (Reimbursed at 80%)

        • Dental expenses incurred for the treatment of an accidental injury to natural teeth or a jaw fracture
        • Certain dental surgical expenses

        Other Services and Supplies (Reimbursed at 80%)

        • Expenses for certain supplies and services may be eligible, subject to maximums, such as ambulance transportation, hearing aids, orthotics, diabetic supplies and aerotherapeutics devices. Please consult the Public Service Health Care Plan (PSHCP) Directive or the Federal PSHCP Administration Authority web site.

        Out-of-Province Emergency Medical Expenses (Reimbursed at 100%)

        • Emergency treatment of injury or illness occurred on vacation or business travel: Maximum $1 million per trip (Canadian currency)
          • For vacation travel: Only emergency services obtained within 40 days of departure date from your province/territory of residence are covered
          • For business travel: Emergency services for the entire period while on "official travel status" are covered

          Out-of-Province Referral Benefit (Reimbursed at 80%)

          • Coverage for certain medical services not available in the province or territory of residence: $25,000 per illness or injury
            • Written referral by the attending physician is required

            Hospital Provision

            Hospital (Reimbursed at 100%)

            • Specified dollar amounts per day, for daily hospital accommodation charges in a licensed hospital not covered by a provincial/ territorial health care plan
            • Three levels of coverage available, each providing a different maximum towards a semi-private or private hospital accommodation:
              • Level I – $90 per day
              • Level II – $170 per day
              • Level III – $250 per day

              Co-ordination of Benefits

              If you and your dependant(s) are covered under more than one group health plan, you may coordinate benefits up to 100% of the actual eligible expenses. Coordination of benefits between PSHCP members is allowed.

              Cost Sharing / Contributions

              The PSHCP monthly contribution rates are comprised of two components, the cost associated with the Extended Health Provision and the cost for the Hospital Provision. These components have different cost sharing arrangements.

              Active Member

              • Your employer pays the full cost of the Extended Health Provision and Hospital Level I coverage under the Hospital Provision. If you choose Hospital Level II or III coverage, you are responsible for 100% of the additional expense for this coverage.
              • Provisions are available for contributions while on leave without pay
              • Provisions are available for members of the Executive Group and other designated groups - Full Employer-Paid Coverage

              Retired Member

              • You and your employer share the cost of the Extended Health Provision and Hospital Level I coverage under the Hospital Provision. If you choose Hospital Level II or III coverage, you are responsible for 100% of the additional expense for this coverage.
              • As of April 1, 2018, you pay 50% of the cost of your Extended Health Provision coverage

              Public Service Health Care Plan Relief Provision

              If you joined the PSHCP as a retired member, you may be eligible for the PSHCP Relief Provision.

              The Relief Provision has been extended to include members who retire between April 1, 2015, and March 31, 2025. This means that if a member retires before March 31, 2025, they may be eligible for reduced contribution rates at the 25:75 (Retired member: Employer) cost-sharing ratio, provided they meet the following criteria:

              • In receipt of a Guaranteed Income Supplement (GIS) benefit; or
              • Has a net or combined net income lower than the GIS threshold

              To apply, complete a PSHCP Relief Provision Application Form and return it to your pension office or the Pension Centre. For the most current GIS threshold amounts, visit the Service Canada website.

              If you are approved for the relief provision, it will be applied on the first day of the second month after the Pension Centre receives your completed application form.

              You and your employer share the cost of the Extended Health Provision and Hospital Level I coverage under the Hospital Provision. If you choose Hospital Level II or III coverage, you are responsible for 100% of the additional expense for this coverage.

              Coverage ends automatically

              • When a member and/or dependant ceases to be eligible.