To be eligible for reimbursement under the Plan, expenses for drugs must first meet the following conditions:
- The expenses must be the reasonable and customary charges, in accordance with the Plan’s formulary.
- The drug must be prescribed by a physician, dentist, nurse practitioner or other qualified health professional if the applicable provincial/territorial legislation permits them to prescribe the drugs.
- The drug must be dispensed by a pharmacist or physician.
While mandatory, these conditions are not sufficient for a drug to be covered by the Plan. Eligible expenses for drugs and related devices are identified below, and specific drugs that are not eligible for reimbursement are defined in the exclusions section.
Eligible expenses are limited to 80% of a drug cost that has been established by the Plan Administrator in their price file. When you use your PSHCP benefit card to purchase a prescription, the pharmacist is required to accept the price paid by Canada Life for eligible prescription drugs and medical supplies. This price file applies across Canada and represents the normal mark-up and cost that the pharmacy can charge. Because the price file is monitored electronically through the use of the benefit card, if you do not use the card when purchasing your prescription, you may be charged more than the established price file. If this occurs, when you submit your paper or electronic claim to Canada Life, it will be evaluated based on the price file amount and your reimbursement will be reduced.
Drug benefit eligible expenses
Aerochambers with masks for the delivery of asthma medication, regardless of the age of the patient.
Drug delivery devices to deliver asthma medication, which are integral to the product, and approved by the Administrator.
Specialised formulas for infants with a confirmed intolerance to both bovine and soy protein. the attending physician or nurse practitioner must confirm this intolerance in writing.
Compound drugs containing at least one active ingredient with a Drug Identification Number (DIN) that is eligible under the PSHCP.
Contraceptives, including oral contraceptives, non-oral contraceptives such as patches, vaginal rings, contraceptive implants (intrauterine and arm), and intrauterine devices (IUDs), including copper IUDs; excludes expenses for contraceptives that are barrier methods, such as male or female condoms, diaphragm and cervical caps, as well as spermicide products such as foams and jellies.
Erectile dysfunction drugs, limited to a maximum eligible expense of $500 per calendar year.
Injectable drugs, including allergy serums administered by injection.
Life-sustaining drugs that may not legally require a prescription and are identified in Schedule VII of the Plan Document.
Drugs that legally require a prescription and are identified in the Monographs section of the current Compendium of Pharmaceuticals and Specialities as a narcotic, controlled drug, or requiring a prescription, except for those specified in the General Exclusions and Limitations.
Replacement therapeutic nutrients prescribed by an accredited medical specialist for the treatment of an injury or disease excluding allergies or aesthetic ailments, to support the life of the participant.
Smoking cessation aids (prescribed by a physician and dispensed by a pharmacist), to a lifetime maximum of $2,000 per participant.
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.
Vitamins and minerals which are prescribed for the treatment of a chronic disease, when in accordance with customary practice of medicine, the use of such products are proven to have therapeutic value and no other alternatives exist.
A Prior Authorization program is in place for a sub-set of specific prescription drugs that require special handling. Prior Authorization is a process administered by the Plan Administrator where certain drugs need to be preapproved before they are reimbursed under the PSHCP. The list of drugs and drug supplies requiring prior authorization is established and maintained by the Plan Administrator.
Mandatory Generic/Biosimilar Substitution
All prescription drugs covered under the PSHCP are reimbursed at 80% of the cost of the lowest-cost alternative drug. The same applies to biologic drugs, which are reimbursed at 80% of the cost of the lowest-cost biosimilars. Exceptions may be granted based on 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.
Pharmacy Dispensing Fees and Frequency Limits
Dispensing Fee Caps
All pharmacies charge dispensing fees, also known as professional fees, to issue a prescription drug. Dispensing fees vary between pharmacies, and they are charged for services, such as storing and preparing medication, prescription verification, and medication reviews to check for interactions and counselling. They are a common industry practice among employer-sponsored plans. They serve as a cost-sharing mechanism between the plan sponsor and the plan member, similar to the co-payment. The dispensing fees cap does not apply to biologic or compound drugs. PSHCP members and their eligible dependants are covered for up to $8, reimbursed at 80%, per pharmacy dispensing fees. Exceptions may apply to some provinces or territories due to pharmacy regulations.
The PSHCP has a Dispensing Fee Frequency Limit, which limits the number of dispensing fees covered under the PSHCP for the same drug within a calendar year. The frequency limit only applies to maintenance drugs. Members and their eligible dependants can claim up to 5 dispensing fees per year for maintenance medications under the PSHCP. To reduce the number of times a dispensing fee is charged and to stay within the annual limit, members can speak to their pharmacy to inquire if a 90-day supply of the maintenance medications can be provided.
Exceptions will be considered in situations such as:
- safety concerns with the prescribed drug (for example, controlled substance, compliance packaging/blister packs, etc.)
- storage limitations for the prescribed drug (for example, requiring deep freeze temperatures)
- the prescribed drug’s 3-month supply co-pay is more than $100
- a member holding Comprehensive Coverage
To request an exception, a member and their prescribing health care provider will need to complete the Request for Dispense Fee Frequency Limit Exception form. Members can find this on the Forms page of the PSHCP Member Services website. Alternately, you can contact Canada Life to request the form be sent by mail.
No benefit is payable for:
- Expenses identified in the General Exclusions and Limitations of the Plan
- Experimental drugs
- Items or products considered to be household remedies
- Vitamins, minerals, and protein supplements, unless they qualify under Eligible expenses
- Therapeutic nutrients, unless they qualify under Eligible expenses
- Diets and dietary supplements, infant foods, and sugar or salt substitutes, unless these qualify under Eligible Expenses
- Lozenges, mouthwashes, non-medicated shampoos, contact lens care products, and skin cleansers, protectives or emollients
- Drugs used for cosmetic purposes
- Drugs used for conditions not recommended by the drug manufacturer (off-label indications)
- Expenses payable under a provincial/territorial drug plan, regardless of whether the participant is covered by that plan.