Understanding Reasonable and Customary Charges (R&C)

1 May 2025

Did You Know?

Acupuncture services provided by a registered acupuncturist are eligible under the Public Service Health Care Plan. No prescription is required.
Read more about the Medical Practitioners Benefit

All expenses claimed under the PSHCP are subject to reasonable and customary (R&C) charges.

This ensures that reimbursements align with standard market rates for health services and products, promoting fairness and sustainability within the plan.

What Are Reasonable and Customary Charges?

“Reasonable and customary charges” (R&C) means the established maximum charge that an insurance carrier will reimburse for specific services and products in the province/territory where the expense is incurred. These charges are based on the amount typically charged to a person without private health care coverage.

Canada Life, the Plan Administrator, determines the appropriate R&C by consulting relevant published fee guides from national and provincial/territorial associations of practitioners, where applicable. The R&C charges for eligible services and products are regularly updated to reflect current market rates and vary by geographical location.

For drug expenses, R&C limits are determined by the PSHCP’s pharmacy benefits manager, TELUS Health.

Importance of R&C Limits

R&C limits are important to ensure claims to your benefits plan are not excessive. Therefore, smart shopping for health-care products and services helps you by not only reducing your out-of-pocket expenses but also by helping to reduce plan costs. R&C limits also help to reduce the likelihood of benefits fraud or abuse. R&C limits are a common practice across most health care plans.

How R&C Limits Affect Reimbursements

When processing claims, the PSHCP will consider the R&C limit for the specific service or product in your province or territory. If the amount of your claim is higher than the established R&C, your reimbursement will be equivalent to 80% of the established R&C charges, not the full cost of your claim.

For example:

If the R&C limit for a one-hour chiropractic treatment in your province is $80.00, and you are charged $100.00, your reimbursement will be 80% of $80.00, for a total of $64.00.

Determining the Applicable R&C Limit

The R&C limit is based on the location where the service is provided, not where you reside. For example, if you live in Ontario but receive treatment from a provider in Quebec, the R&C limit for Quebec will apply to that service.

Accessing R&C Information

To find out the R&C limit for a specific service before incurring an expense:

  1. Sign in to your PSHCP Member Services account at https://www.canadalife.com/pshcp.
  2. Navigate to the “Benefits” section.
  3. Click on “Coverage and balances” and then “Health, Drugs, Vision.”
  4. Select the type of coverage for which you want to know the R&C’s (Example: Medical Practitioners or Vision Care)
  5. Select the type of service you want to know the R&C’s for (Example: Acupuncture)
  6. Follow the prompts to learn the R&C’s and ensure that the appropriate province and year are selected.

Reviewing R&C charges before incurring an expense allows you to make informed decisions and avoid unexpected out-of-pocket costs.

Note: R&C limits for medical devices or products are not available online. To confirm the R&C limit for an eligible device or product, you are encouraged to submit an estimate to Canada Life before making a purchase.

Need Assistance?

If you have questions about R&C charges or need further information: Please visit Canada Life’s Member Services Website or contact the Canada Life PSHCP Member Contact Centre