In this issue:
- Working to make things right – A message from Canada Life
- NEW: Urgent needs escalation process
- Reminder: Submitting claims to Canada Life
- Reminder of changes to the PSHCP Drug Benefit
- Mandatory Generic Substitution
- Biosimilar Substitution
- At the Pharmacy
- MSH – Your emergency travel assistance and Comprehensive Coverage provider
Working to make things right – A message from Canada Life
On July 1, 2023, Canada Life™ became the new administrator of your Public Service Health Care Plan (PSHCP). During the transition, some plan members did not experience reliable access to our PSHCP Member Contact Centre and our website. We hear you. Nothing is more important to us than members getting the help they need, and we are continuing to work to improve our services. We thank you for your patience and understanding.
NEW: Urgent needs escalation process
Canada Life has introduced an escalation process for urgent claims to be quickly identified and prioritized. If you have already submitted your claim and it is for urgent, life-sustaining prescription drugs, services, or treatments, or you are a person with a disability, you can contact the Canada Life escalation team by email at Urgent_PSHCP@canadalife.com. Include your plan and certificate numbers and why your claim should be escalated.
Reminder: Submitting claims to Canada Life
All claims must now be sent to Canada Life for processing, even if the expense(s) were incurred before July 1, 2023. To make submitting claims easier and to get the latest information about your benefits, create a PSHCP Member Services account at canadalife.com/pshcp, if you have not already done so. From your account, you can:
- submit claims
- obtain your PSHCP benefit card
- review your coverage and balances
- check drug and provider eligibility
- provide banking information on a secure form to enable direct deposit of claim reimbursements
- as an employee, link your PSHCP and Public Service Dental Care Plan (PSDCP) to view both plans under one account, if applicable
If you prefer to submit paper claim forms, you can download and print one from the Your forms page of the PSHCP Member Services website. Once the form is complete, sign and submit it to Canada Life using the address found on the form. You can also call the PSHCP Member Contact Centre to request that a paper form be sent to you. Registered health care providers can now submit claims directly to Canada Life on your behalf with Provider eClaims. This means you simply pay the 20% co-payment amount at the point of sale.
Reminder of changes to the PSHCP Drug Benefit
Negotiated improvements and changes to the PSHCP came into effect on July 1, 2023. These were detailed in your Bulletin 45. Some of these changes were to the PSHCP Drug Benefit and include Mandatory Generic Substitution, Biosimilar Substitution, Dispensing Fee and Dispensing Fee Frequency Limits.
Mandatory Generic Substitution
Mandatory generic drug substitution is in effect for all new drug prescriptions issued on or after July 1, 2023. This means that you and your eligible dependant(s) are reimbursed at 80% of the cost of the lowest-cost generic drug equivalent, where one exists, unless there is an exception on file. Generic medications are safe and effective alternatives to brand name drugs and are reviewed and approved by Health Canada. Generics contain identical active ingredients as the brand name drug.
Note: Until December 31, 2023, brand name drug prescriptions issued before July 1, 2023, will continue to be reimbursed at 80%. However, starting January 1, 2024, if you or your eligible dependant(s) are prescribed or are taking a brand name drug, you have three options:
- Switch to the lowest-cost alternative generic drug.
- Pay the difference between the cost of the generic drug and the brand name drug.
- Discuss the issue with a medical professional, and if they believe that the brand name drug is required rather than the generic equivalent, ask them to complete the Request for Brand Name Prescription Drug Coverage Form and submit it to Canada Life. If approved, the PSHCP will pay the applicable cost of the brand name drug.
Originator biologic drugs and biosimilar drugs are reviewed and approved by Health Canada. Biosimilars are highly similar in terms of quality, efficacy and safety to originator biologics that have previously been authorized for use. If you or your eligible dependant(s) are on an originator biologic where a biosimilar is available, Canada Life may contact you with details regarding the switch to a biosimilar equivalent drug. Claims for originator biologics may be denied or have their reimbursement limited to 80% of the lowest-cost biosimilar. Members with existing originator biologic treatments may be contacted by Canada Life and will be provided with details regarding the switch to a biosimilar equivalent drug. If there is a medical reason to stay on the originator biologic, your attending physician or nurse practitioner can fill out a Request for Originator Biologic Drug Coverage Form. If approved, the PSHCP will pay the applicable cost of the brand name originator biologic.
At the Pharmacy
Dispensing Fee Cap
The PSHCP pays up to $8, reimbursed at 80%, for pharmacy dispensing fees. The dispensing fee cap does not apply to specialty or compound drugs.
Dispensing Fee Frequency Limit
The PSHCP has a Dispensing Fee Frequency Limit that allows for the reimbursement of five separate dispensing fees, per year, per drug, when the fee is associated with a maintenance medication. The Dispensing Fee Frequency Limit only applies to maintenance drugs and may not apply in some provinces or territories due to pharmacy regulations. To avoid paying unnecessary dispensing fees, speak to your pharmacist about providing a 100-day supply of your maintenance drug(s). Exceptions will be considered where:
- there are safety concerns or storage limitations with the prescribed drug
- the prescribed drug’s three-month supply co-pay is more than $100
To request an exception, you and your attending physician or nurse practitioner will need to complete the Dispense Fee Frequency Limit Exception Form. The Day Supply Limit for drugs under the PSHCP is 100 days for both acute and maintenance drugs, however if you are travelling for an extended period, you can request an increase to your Day Supply Limit for up to 200 days from your pharmacist. Provide your PSHCP benefit card and medication list to your pharmacist at least two weeks before your travels and ask them to submit your request using the Day Supply Limit for prescription medication instructions. To find the forms mentioned above, please visit the Your forms page of the PSHCP Member Services website or call the PSHCP Member Contact Centre to request that paper forms be sent to you. For more information about the PSHCP design changes, please see your PSHCP Bulletin 45.
MSH – Your emergency travel assistance and Comprehensive Coverage provider
MSH International (MSH) is your new emergency travel assistance and Comprehensive Coverage provider. If you prefer to file claims electronically you are encouraged to register for the MSH PSHCP Member Portal at pshcp-msh.ca to submit, review and receive reimbursements for your emergency travel assistance and Comprehensive Coverage claims faster. To register or sign in to the MSH PSHCP Member Portal, you will need to use the email address you used for your PSHCP Member Services account. Members who prefer to submit paper claims can download a form from pshcp-msh.ca or have a form mailed to them by calling the Emergency Travel Assistance Services and Comprehensive Coverage Contact Centre at the phone numbers provided. While travelling, eligible expenses under the PSHCP can be submitted to Canada Life or MSH, depending on the type of expense incurred. Use the table below to find out where to send your claim(s).
Submit the following claims to Canada Life
- Non-emergency claims for expenses incurred within Canada for all PSHCP members.
- Non-emergency claims for expenses incurred outside of Canada for members with Supplementary Coverage.
Submit the following claims to MSH
- Emergency Travel Assistance claims for members with Supplementary Coverage. These are the eligible medical expenses incurred as a result of an emergency while travelling on vacation or on business while outside the province or territory of residence.
- All claims for expenses incurred outside of Canada for members with Comprehensive Coverage.
Be sure to carry your PSHCP benefit card while travelling. It provides the MSH phone number and the information you will need to submit a claim. If you have any questions about your emergency travel assistance and Comprehensive Coverage or the
MSH PSHCP Member Portal, please contact MSH at:
North America (toll-free): 1-833-774-2700
International (collect): 1-365-337-7427