PSHCP Bulletin 52

Contents

• Supplementary and Comprehensive Coverage
• PSHCP Contribution rates
• How the PSHCP is designed and administered
• What are Reasonable and Customary Charges?
• Appealing a claim decision
• Prior Authorization Program: Step therapy
• Is your expense eligible for reimbursement?
• New application form for dependants with a disability

Supplementary and Comprehensive Coverage

Coverage types

The Public Service Health Care Plan (PSHCP) provides reimbursement for many health-related expenses through two coverage types:

1. Supplementary Coverage: is voluntary for eligible members and their dependants who live in Canada and are covered by a provincial or territorial health insurance plan. The majority of PSHCP members have Supplementary Coverage as it supplements their provincial or territorial health insurance plan. Supplementary Coverage also provides up to $1 million (Canadian) reimbursed at 100% in eligible medical expenses due to a medical emergency when travelling outside of your province/territory/country of residence.
2. Comprehensive Coverage: is mandatory for eligible members and their dependants who are deployed or posted outside of Canada at their Employer’s request. Retired members (pensioners) who live outside Canada and are no longer eligible for coverage under a provincial or territorial governmental health insurance plan or a non-government hospital insurance plan can choose Comprehensive Coverage.

Changing your coverage type

If you need to convert your coverage from Supplementary to Comprehensive or vice versa, please complete a PSHCP Employee Application Form (pshcp.ca/wp-content/uploads/2013/06/emp-applic-adhes-006491.pdf) or the PSHCP Pensioner Application Form (pshcp.ca/wp-content/uploads/2013/06/pens-applic-adhes-006492-2.pdf) and submit it to your departmental compensation office, Pay Centre or the Government of Canada Pension Centre.

When can you change coverage types:

• From Supplementary to Comprehensive: An employee must have Comprehensive Coverage if they are not covered under a provincial/territorial health plan or under a non-government hospital insurance plan because of deployment or posting outside Canada by their Employer. A pensioner can choose Comprehensive Coverage when living outside of Canada.
• From Comprehensive to Supplementary: An employee who returns to Canada and is again covered under a provincial or territorial health plan must convert their coverage.

For more information on the coverage types under the PSHCP, please refer to the PSHCP Member Booklet (canadalife.com/content/dam/rfp/welcome-sites/pshcp/PSHCP-member-booklet.pdf).

PSHCP Contribution rates

The PSHCP is equally cost-shared between the Government of Canada and retired members. Following the annual rate analysis to maintain the 50:50 cost sharing ratio, monthly contribution rates for retired members with Supplementary Coverage will be adjusted.

New contribution rates effective April 1, 2026

The tables below provide the monthly contribution rates for retired members with Supplementary Coverage. The new rates will be reflected on retired members’ March 2026 pension payments for April 2026 coverage, as contributions are owed one month in advance.

The tables show the breakdown of the contribution rates for the Extended Health Provision (EHP) and the Hospital Provision (HP) with a total amount paid by the retired member each month.

Retired Member Monthly Contribution Rates: Supplementary Coverage

TYPE OF COVERAGE

SINGLE RATE	EHP	HP	Total
Hospital Level I	$76.32	$0.00	$76.32
Hospital Level II	$76.32	$8.40	$84.72
Hospital Level III	$76.32	$23.22	$99.54
FAMILY RATE	EHP	HP	Total
Hospital Level I	$169.12	$0.00	$169.12
Hospital Level II	$169.12	$12.14	$181.26
Hospital Level III	$169.12	$29.37	$198.49

Retired Member Monthly Contribution Rates: Supplementary Coverage – Relief Provision

Type of Coverage

SINGLE RATE	EHP	HP	Total
Hospital Level I	$38.16	$0.00	$38.16
Hospital Level II	$38.16	$8.40	$46.56
Hospital Level III	$38.16	$23.22	$61.38
FAMILY RATE	EHP	HP	Total
Hospital Level I	$84.56	$0.00	$84.56
Hospital Level II	$84.56	$12.14	$96.70
Hospital Level III	$84.56	$29.37	$113.93

PSHCP Employer Rate

The Government of Canada (the Employer) has an Employer Rate which is used to calculate contribution rate payments for certain employees on Leave Without Pay, and for participating separate employers. The PSHCP Employer Rate, effective April 1, 2026, is $198.75.

How the PSHCP is designed and administered

PSHCP benefits, including maximums and limitations, are negotiated by representatives from the Government of Canada, Bargaining Agents and retiree representatives.

Canada Life, as the PSHCP administrator, processes claims and issues reimbursements according to the negotiated provisions of the PSHCP and industry best practices.

Claims for Emergency Travel and Comprehensive Coverage are processed by MSH International (MSH), Canada Life’s subcontractor for international services.

What are Reasonable and Customary Charges?

All expenses claimed under the PSHCP are subject to Reasonable and Customary Charges. Reasonable and Customary Charges are the established maximum amounts that can be reimbursed for a specific product or service in the province/territory where the expense was incurred. These amounts are based on the typical pricing in the area where the expense is incurred, as well as on professional association fee guides, if applicable. Reasonable and Customary Charges are regularly updated to reflect current market rates.

When you submit a claim, Canada Life will consider the Reasonable and Customary Charges limit for the service or product in your province/territory. For example, if you pay $75 for a one-hour chiropractic treatment and the Reasonable and Customary Charge in your area is $60, you will be reimbursed 80% of $60 (which is $48). The remaining amount of $15 ($75 minus $60), is considered ineligible and you must pay for this yourself.

To learn more, please visit the PSHCP Member Booklet (canadalife.com/content/dam/rfp/welcome-sites/pshcp/PSHCP-member-booklet.pdf) or read Understanding Reasonable and Customary Charges on the Federal PSHCP Administration Authority website (pshcp.ca/articles/understanding-reasonable-and-customary-charges-rc).

Appealing a claim decision

If you do not agree with the outcome of your claim, there are two steps you must follow:

1. Contact Canada Life or MSH (if your claim was filed with MSH) to request that your claim be re-evaluated. Once all avenues of review with Canada Life have been exhausted, you can then go to step two.
2. Submit an appeal to the Federal PSHCP Administration Authority (pshcp.ca/appeals) which oversees the administration of the PSHCP. Appeals must be submitted in writing to the Federal PSHCP Administration Authority, within 12 months of the date on your explanation of benefits.

If your appeal is related to your coverage level (e.g. Single versus Family coverage, Comprehensive versus Supplementary Coverage) or your hospital coverage level:

1. Contact your departmental compensation office, the Pay Centre or the Pension Centre for guidance on next steps. If this does not resolve your issue, you can go to step two.
2. Submit an appeal to the Federal PSHCP Administration Authority.

Prior Authorization Program: Step therapy

The PSHCP Prior Authorization Program is a process where certain prescription drugs may require pre-approval before they can be reimbursed under the PSHCP. To receive prior authorization for the reimbursement of certain prescription drugs, you should submit a request and obtain approval from Canada Life before starting your treatment.

Prior authorization provides an opportunity for you, or your eligible dependant(s), to talk with your medical professional about treatment options. This process is intended to promote other recommended, and less expensive but equally effective treatments, where medically appropriate.

For a claim to be eligible for a drug that is part of the PSHCP Prior Authorization Program, a determination must be made by Canada Life that the prescription drug is being used for a condition and dosage approved by Health Canada.

To be approved under the PSHCP Prior Authorization Program, a process called step therapy may also apply.

What is step therapy?

Step therapy is the process where, when medically appropriate, clinically acceptable and cost-effective drugs are the first course of action for your treatment. More expensive, or “second-line” drugs may be available after you try a first-line treatment.

Where step therapy is applicable, your physician must provide medical information, including previous therapies which were tried, prior to allowing coverage. If you request coverage of a drug subject to the PSHCP’s Prior Authorization Program, Canada Life will assess whether the prescribed drug represents reasonable treatment for your medical condition and an appropriate step therapy approach, if applicable.

If you have not tried the required alternatives and your physician does not provide information for why, coverage will be declined and you will be required to pay out of pocket for the drug.

Note: Not all drugs subject to the PSHCP’s Prior Authorization Program require step therapy. For some conditions, there are no other treatment alternatives.

Where can I find more information about the Prior Authorization Program?

For a listing of the prescription drugs that require prior authorization, visit the Forms page of the PSHCP Member Services website (welcome.canadalife.com/pshcp/forms). You can also call the PSHCP Member Contact Centre to request that a paper form be mailed to you.

To learn more about the PSHCP Prior Authorization Program, please review the Prior Authorization Program: what you need to know article in Bulletin #50 (welcome.canadalife.com/pshcp/news-and-updates/bulletin-50.html).

Is your expense eligible for reimbursement?

The PSHCP provides coverage for a wide variety of health-related products and services, however, limitations may apply. For example, the Psychological Services Benefit under the PSHCP provides coverage for up to $5,000* per calendar year, from an eligible provider. Eligible providers are psychologists, social workers, psychotherapists and counsellors, as deemed qualified by Canada Life based on provincial/territorial accreditation. You can find eligible providers under the Medical Practitioners Benefit section in your PSHCP Member Booklet (canadalife.com/content/dam/rfp/welcome-sites/pshcp/PSHCP-member-booklet.pdf), the PSHCP Directive (njc-cnm.gc.ca/directive/d9/en), or consult the Coverages and balances section of your PSHCP Member Services account (canadalife.com/pshcp). If you are unable to locate the information you need, please call Canada Life before incurring your expense.

*Coverage for the Psychological Services Benefit is 80% of $5,000 per calendar year, limited to the hourly Reasonable and Customary Charges for your province/territory.

New application form for dependants with a disability

A new Application for Dependant with a Disability Coverage form is now available and must be used when applying for coverage for a dependant child with a disability. The single form can be applied to the PSHCP and the Public Service Dental Care Plan (PSDCP) or the Pensioners’ Dental Services Plan (PDSP). When submitting this form, please select the plan(s) under which you wish to apply for coverage.

Make sure to review the Rules for each plan in the Eligibility section of your member booklets. The booklets can be found on the Your plan page of the PSHCP, PSDCP and PDSP Member Services websites (welcome.canadalife.com/ps-health-dental).

You can find the application form for your dependant with a disability on the Forms page of the PSHCP Member Services website (www.welcome.canadalife.com/pshcp/forms.html) or call Canada Life to request that a form be mailed to you.

If you have any questions, please sign in to your PSHCP Member Services account through My Canada Life at Work^TM or call the PSHCP Member Contact Centre for inquiries within North America (toll-free) at 1-855-415-4414, Monday to Friday from 8 am to 5 pm, your local time, or for international inquiries (collect) at 1-431-489-4064, Monday to Friday from 8 am to 5 pm, ET.