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Extended Health Provision
Drug Benefit
Maximum Eligible Expense: Effective July 1, 2023, eligible drug expenses in excess of $3,500 out-of-pocket drug expense incurred in a given calendar year payable at 100%
If $3,000 of out-of-pocket drug expenses were incurred before July 1, 2023, an additional $500 of out-of-pocket drug expenses must be incurred to receive 100% reimbursement for purchases made after July 1, 2023
PSHCP Pays: 100%
Maximum Eligible Expense: Reasonable and customary charges, in accordance with the Plan’s formulary.
PSHCP Pays: 80%
Maximum Eligible Expense: $500 every calendar year on a combined basis
PSHCP Pays: 80%
Maximum Eligible Expense: $2,000 in a lifetime
PSHCP Pays: 80%
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
Exclusions
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.
Vision Care Benefit
Maximum Eligible Expense: One examination every two calendar years commencing every odd year
PSHCP Pays: 80%
Maximum Eligible Expense: $400 every two calendar years commencing every odd year. No limit if required as a result of surgery or accident and purchased within six months of the event
PSHCP Pays: 80%
Maximum Eligible Expense: $2,000 per lifetime.
PSHCP Pays: 80%
Exclusions
No benefit is payable for:
- Eye-related procedures which use lasers but where the laser does not reshape the cornea with the goal of correcting common vision problems;
- Expenses identified in the General Exclusions and Limitations of the Plan.
Medical Practitioners Benefit
No prescription required.
Services can be provided by a registered acupuncturist.
Maximum Eligible Expense: $500 per calendar year
PSHCP pays: 80%
No prescription required.
Maximum Eligible Expense: $500 in a calendar year
PSHCP pays: 80%
No prescription required.
Maximum Eligible Expense: $300 per calendar year.
PSHCP pays: 80%
A prescription is required unless the plan participant is undergoing treatment related to gender affirmation.
Maximum Eligible Expense: $1,200 per calendar year
PSHCP pays: 80%
No prescription required.
Services covered by the province or territory of residence must be exhausted first
Maximum Eligible Expense: $300 per calendar year
PSHCP pays: 80%
No prescription required.
Maximum Eligible Expense: $500 in a calendar year
If $300 of massage claims were incurred before July 1, 2023, an additional $200 can be claimed for services incurred on or after July 1, 2023.
PSHCP pays: 80%
No prescription required.
Maximum Eligible Expense: $500 in a calendar year.
If $300 of naturopath claims were incurred before July 1, 2023, an additional $200 can be claimed for services incurred on or after July 1, 2023.
PSHCP pays: 80%
No prescription required.
Services covered by the province or territory of residence must be exhausted first.
Maximum Eligible Expense: $300 per calendar year.
PSHCP pays: 80%
No prescription required.
Maximum Eligible Expense: $500 in a calendar year.
If $300 of osteopath claims were incurred before July 1, 2023, an additional $200 can be claimed for services incurred on or after July 1, 2023.
PSHCP pays: 80%
No prescription required.
Maximum Eligible Expense: $1,500 in a calendar year.
After July 1, 2023, the full amount of $1,500 will be available for the remainder of 2023.
PSHCP pays: 80%
No prescription required.
Foot care provided by a licensed nurse in a community nursing station will be reimbursed under this benefit.
Maximum Eligible Expense: $500 in a calendar year (combined)
If $300 of podiatrist or chiropodist claims were incurred before July 1, 2023, an additional $200 can be claimed for services incurred on or after July 1, 2023
PSHCP pays: 80%
No prescription required.
Mental health services can be provided by the following providers in the location in which they work:
- Psychologists
- Social Workers
- Psychotherapists
- Counsellors, as deemed qualified by the plan Administrator based on provincial/ territorial accreditation.
Maximum Eligible Expense: $5,000 in a calendar year (combined)
If $2,000 of claims for psychological services were incurred before July 1, 2023, an additional $3,000 can be claimed for services incurred after July 1, 2023.
PSHCP pays: 80%
No prescription required.
Maximum Eligible Expense: $750 in a calendar year (combined).
PSHCP pays: 80%
If $500 of speech language pathologist claims were incurred before July 1, 2023, an additional $250 can be claimed for services incurred on or after July 1, 2023.
Exclusions
No benefit is payable for:
- Expenses identified in the General Exclusions and Limitations of the Plan
- Expenses for surgical supplies and diagnostic aids
- Expenses for services provided by salaried employees of a facility
Miscellaneous Expense Benefit
Batteries are covered under an initial hearing aid purchase.
This benefit provides coverage for replacement hearing aid batteries.
Maximum eligible expense of $200 per calendar year
For people with Type I diabetes only
Maximum eligible expense of $3,000 per calendar year
A prescription is required.
Eligible with or without an insulin pump
Coverage includes flash glucose monitors, continuous glucose monitors (for type 1 diabetics only), and standard glucose monitor devices.
Combined maximum eligible expense of $700 per 5 years
Eligible for all diabetic types.
Effective July 1, 2023, the full amount of $3,000 for diabetic supplies will be available for the remainder of 2023.
Maximum eligible expense of $3,000 per calendar year.
Coverage for certain services and procedures designed to support and affirm an individual’s gender identity, or to remove gender identity. This benefit includes procedures and services that are not covered by the individual’s provincial/territorial health plan. The services must be rendered in the patient’s country of residence.
To be considered for coverage, the person must:
- Be aged 18 or older.
- Under the care of a physician for gender affirmation
- Exhaust all available coverage offered by the province or territory of residence.
- Have all procedures considered medically necessary by the attending physician/ nurse practitioner.
- Obtain prior approval by completing a Gender Affirmation Application Form to be completed by both the covered person and the attending physician/ nurse practitioner and submitted to the plan administrator for review.
Maximum eligible expense of $75,000 per lifetime
Maximum Eligible Expense: $1,500 less any eligible hearing aid expenses claimed during the previous 60 months
No limit if required as a result of surgery or accident and purchased within 6 months of the event
PSHCP pays: 80%
A prescription is required.
Not eligible for cosmetic purposes.
Maximum eligible expense of $600 per calendar year.
Maximum Eligible Expense: $1000 during a 36-month period
PSHCP Pays: 80%
A prescription is required.
The prescription will be valid for 3 years.
Maximum eligible expense of $200 per calendar year
Maximum Eligible Expense: $200 in a calendar year
PSHCP pays: 80%
Maximum Eligible Expense: $250 in a calendar year
PSHCP pays: 80%
Maximum Eligible Expense: $500 per calendar year
Does not include expenses for cleaning supplies or warranties
If $300 for aerotherapeutic supplies was incurred before July 1, 2023, an additional $200 can be claimed for aerotherapeutic supplies incurred on or after July 1, 2023.
PSHCP pays: 80%
Maximum Eligible Expense: $1,500 in a 60-month period
PSHCP pays: 80%
Exclusions:
No benefit is payable for:
- Items purchased primarily for athletic use;
- Ambulance services for a medical evacution considered eligible under the out-of-province benefit;
- Expenses incurred under any of the conditions listed under General Exclusions and Limitations;
- Durable equipment that is:
- An accessory to an eligible device;
- A modification to the patient’s home (bar, ramp, mat, elevator, etc.);
- Used for diagnostic or monitoring purposes (unless specifically provided under Eligible Expenses);
- An implant (unless specifically provided under Eligible Expenses);
- Bathroom safety equipment;
- An air conditioner;
- Ongoing supplies associated with durable equipment, ongoing supplies associated with durable equipment, except as specifically provided under eligible expenses.
- Durable equipment that is used to prevent illness, disease or injury;
- Devices for a treatment considered to be experimental;
- The portion of charges covered by a provincial/territorial health insurance plan or program, regardless of whether the member is a participant of the plan or program
Out-of-Province Benefit
Maximum Eligible Expense: $1 million per period of travel (not exceeding 40 days)
PSHCP Pays: 100%
Maximum Eligible Expense: $25,000 per illness or injury
PSHCP pays: 80%
Exclusions
No benefit is payable for:
- Expenses incurred outside the Participant’s province/territory of residence if they are required for the emergency treatment of an injury or disease which occurred more than 40 days after the date of departure from the province/territory of residence, except as provided for Members who are on official travel status;
- Expenses incurred by a Participant who is temporarily or permanently residing outside Canada;
- Expenses for the regular treatment of an injury or disease which existed prior to the Participant’s departure from their province/territory of residence;
- Expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions.
Hospital Provision
Maximum Eligible Expense: $90 per day
PSHCP pays: 100%
Maximum Eligible Expense: $170 per day
PSHCP pays: 100%
Maximum Eligible Expense: $250 per day
PSHCP pays: 100%
Exclusions
No benefit is payable for:
- Expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions;
- Co-insurance charges or similar charges for Hospital care which are in excess of charges payable by a provincial or territorial government health or hospital insurance plan, except charges as provided under the terms of the Hospital Provision. However, co-insurance charges for a chronic care Hospital for a patient who is confined to a chronic care Hospital, and has made at least one claim for such charges before September 1, 1992 and makes a further claim for the same period of confinement, are eligible;
- Personal charges such as televisions and telephones;
- Expenses incurred when a patient is occupying an acute care Hospital bed but has been medically discharged and no longer requires acute care.
Basic Health Care Provision
Maximum Eligible Expense: Three times (3x) the amount otherwise payable under the current fee schedule of the Health Insurance Act 1972 of Ontario
PSHCP pays: 100%
Exclusions
No benefit is payable for:
- Expenses identified in the General Exclusions and Limitations of the Plan
- Services performed by a physician who is a salaried employee of a hospital.