Home » Directives » Public Service Health Care Plan Directive » July 1, 2023 » 6 Extended Health Provision

6 Extended Health Provision

6.1  General

6.1.1 The purpose of this provision is to provide coverage for specified services and products which are not covered under provincial/territorial health insurance plans, or alternatively, in the case of members resident outside Canada, which are not covered under the Basic Health Care Provision of the PSHCP. All members of the PSHCP are covered under this provision, except for those with Comprehensive coverage who are not eligible for the Out-of-Province Benefit.

6.1.2 The Extended Health Provision is comprised of the following benefits:

  1. Drug Benefit;
  2. Vision Care Benefit;
  3. Medical Practitioners Benefit;
  4. Miscellaneous Expense Benefit;
  5. Dental Benefit;
  6. Out-of-Province Benefit (for members with Supplementary coverage only):
    1. Emergency Benefit While Travelling,
    2. Emergency Travel Assistance Services,
    3. Referral Benefit.

6.1.3 Some of the aforementioned benefits may be subject to reasonable and customary charges and to certain limits as specified in the Summary of Maximum Eligible Expenses. All are subject to the co-payment except for the Emergency Benefit While Travelling and the Emergency Travel Assistance Services.

6.2  Drug Benefit (For All Members)

6.2.1 To be eligible, expenses must be:

  1. the reasonable and customary charges, in accordance with the Plan’s formulary;
  2. prescribed by a physician, dentist, nurse practitioner (if authorized by provincial/territorial legislation), or other qualified health professional if the applicable provincial/territorial legislation permits them to prescribe the drugs; and
  3. dispensed by a pharmacist or physician.

6.2.2 Eligible expenses are:

  1. drugs which legally require a prescription and are identified in the Monographs section of the current Compendium of Pharmaceuticals and Specialties as a narcotic, controlled drug, or requiring a prescription, except for those specified under Exclusions listed in this section;
  2. limited to 80% of a drug cost that has been established by the Plan Administrator in their price file, and determined to be reasonable and customary, when accessed by a member using the PSHCP Benefit Card. The 20% co-payment that a member is responsible for, notwithstanding expenses in excess of the Plan Administrator’s price file that may be incurred by not using the PSHCP Benefit Card, will not be reimbursed by the PSHCP.
    1. expenses associated with eligible drug claims incurred by members when posted or travelling outside Canada that cannot be submitted by the pharmacist by using the PSHCP Benefit Card are reimbursed at 80% of the paid amount,
    2. limited to the lowest cost alternative of a generic drug, where a generic drug exists that is associated with the Plan Administrator’s price file, unless a PSHCP Drug Exception form is completed and approved by the Plan Administrator;
  3. life-sustaining drugs which may not legally require a prescription and are identified in Schedule VII of this Plan Document;
  4. replacement therapeutic nutrients prescribed by an accredited medical specialist for the treatment of an injury or disease excluding allergies or aesthetic ailments, provided that there is no other nutritional alternative to support the life of the participant;
  5. injectable drugs, including allergy serums administered by injection;
  6. compound drugs containing at least one active ingredient with a Drug Identification Number (DIN) that is eligible under the PSHCP;
  7. 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 is proven to have therapeutic value, and it is confirmed by a physician or nurse practitioner that no other alternatives are available to the patient;
  8. drug delivery devices to deliver asthma medication, which are integral to the product, and approved by the Plan Administrator;
  9. aerochambers with masks for the delivery of asthma medication;
  10. specialized formulas for infants with a confirmed intolerance to both bovine and soy protein. The attending physician, or nurse practitioner, must confirm in writing that the infant cannot tolerate any other formula or feeding substitute;
  11. smoking cessation aids, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses;
  12. 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;
  13. erectile dysfunction drugs, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses.

PSHCP Benefit Card

6.2.3 Members may use their benefit card to purchase prescription medication to a maximum of 100 days for all PSHCP-eligible drugs. Members travelling and requiring more than a three-month supply may contact the Plan Administrator who can add such a notation to the file. The card may also be used to purchase the following eligible medical supplies at pharmacies in Canada: diabetic supplies (syringes, lancets, and glucose test strips), catheter supplies, and dressing and bandages. To be eligible for reimbursement, these medical supplies require a prescription. All other expenses may be submitted electronically using the Plan Administrator’s website or mobile application.

6.2.4 With the introduction of the PSHCP Benefit Card in 2010, the PSHCP has adopted the same practice as many provincial drug programs that require pharmacists to dispense the lowest-cost alternative medication, and charge the price based on the Plan Administrator’s price file which represents the reasonable and customary mark-up and ingredient cost by province. Pharmacists may not charge more than the cost indicated in the price file to members using the PSHCP Benefit Card. However, pharmacists may charge their normal costs to individuals who opt to not use the benefit card, and the Plan member will be responsible for the difference between the amount charged and the price file as the excess amount will not be eligible under the PSHCP.

Prior Authorization

6.2.5 The Plan Administrator will assess whether a prescribed drug is subject to the PSHCP’s Prior Authorization program and represents an appropriate step therapy approach to reasonable treatment for the Plan participant’s medical condition.

6.2.6 The list of drugs and drug supplies requiring prior authorization will be established and maintained by the Plan Administrator. This list may include, but is not limited to, generic and biosimilar products as they become available and where evidence and Health Canada approvals become available.

6.2.7 The Plan Administrator may deny any expense for a drug that appears on the prior-authorization list. The Plan Administrator will regularly review and may add or remove a drug from the list. For greater certainty, a drug may be added to the list if:

  1. the Plan Administrator determines that further information from professional advisory bodies, government agencies or the manufacturer of the drug is necessary to assess the drug; or
  2. the Plan Administrator determines that the drug is not proportionate to the disease or injury or, where applicable, the stage or progression of the disease or injury.

6.2.8 The Plan Administrator may deny any drug that the Plan Administrator has determined is not proportionate to the disease or injury or, where applicable, the stage or progression of the disease or injury. In determining whether a drug is proportionate, the Plan Administrator may consider:

  1. clinical practice guidelines;
  2. assessments of the clinical effectiveness of the service or supply, including by professional advisory bodies or government agencies;
  3. information provided by a manufacturer or provider of the service or supply; and
  4. assessments of the cost effectiveness of the service or supply, including by professional advisory bodies or government agencies.

6.2.9 The Plan Administrator may authorize an alternative treatment, prioritizing but not limited to the lowest cost alternative, provided it represents a reasonable treatment for the Plan participant’s medical condition. The Plan Administrator may deny or limit reimbursement to the expenses associated with the approved treatment.

6.2.10 The Plan Administrator may require a Plan participant take part in a patient support program to which the Plan participant is eligible. Refusal to participate in a patient support program may reduce the amount of the authorized covered expense(s) that might have been possible if the Plan participant had applied to the patient support program.

6.2.11 The Plan Administrator may revoke a prior authorization decision, if medical evidence is found to no longer support the drug for which prior authorization was approved.

6.2.12 The Plan Administrator will re-assess approved Plan participant’s prior authorization decisions, depending on the drug and/or medical condition for which approval was granted. The list of drugs and/or medical conditions that require re-assessment will be established by the Plan Administrator.

6.2.13 A Plan participant with Comprehensive coverage may not be subject to the PSHCP’s prior authorization program.

6.2.14 Where a member does not agree with a prior-authorization decision, they may ask the Plan Administrator to review their file. Once all avenues of review with the Plan Administrator have been exhausted, the member may submit an appeal to the PSHCP Administration Authority, as a last course of action. The appeal process is the final review level under the PSHCP.

Mandatory Generic/Biosimilar Substitution

6.2.15 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.

Pharmacy Dispensing Fees and Frequency Limits

6.2.16 The PSHCP will reimburse up to a maximum of $8 for the pharmacy dispensing fee. The fee cap does not apply to biologic or compound drugs.

6.2.17 Pharmacist dispensing fees will be reimbursed up to a maximum of five (5) times per calendar year for maintenance drugs. Exceptions may be granted if the drug is a controlled substance, has a manufacturer recommended storage limitation, or the three-month supply co-pay is more than $100.

6.2.18 Exceptions may apply to some provinces/territories due to provincial/territorial laws.

6.2.19 Members who hold Comprehensive coverage may not be subject to dispensing fee limitations.

Catastrophic Drug Coverage in the Event of High Drug Costs

6.2.20 Catastrophic drug coverage provides protection for members who incur high drug costs in any given calendar year. Under the terms of this provision, eligible drug expenses incurred in a given calendar year will be reimbursed at 80% until a plan member reaches in that same calendar year $3,500 in out-of-pocket drug expenses. Eligible drug expenses incurred during the same calendar year in excess of this threshold will then be reimbursed at 100%.

Exclusions

6.2.21 No benefit is payable for:

  1. expenses for drugs which, in the Plan Administrator’s opinion, are experimental;
  2. publicly advertised items or products which, in the Plan Administrator’s opinion, are household remedies;
  3. expenses for vitamins, minerals, and protein supplements, other than expenses that would qualify for reimbursement under Eligible Expenses;
  4. expenses for therapeutic nutrients other than those that would qualify for reimbursement under Eligible Expenses;
  5. expenses for diets and dietary supplements, infant foods and sugar or salt substitutes, other than expenses that would qualify for reimbursement under Eligible Expenses;
  6. expenses for lozenges, mouth washes, non-medicated shampoos, contact lens care products and skin cleansers, protectives or emollients;
  7. expenses for drugs which are used for cosmetic purposes;
  8. expenses for drugs which are used for a condition or conditions not recommended by the manufacturer of the drugs;
  9. expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions;
  10. expenses which are payable under a provincial/territorial drug plan whether or not the participant is participating in the plan.

6.3  Vision Care Benefit (For All Members)

6.3.1 Eligible expenses are the reasonable and customary charges for the following items:

  1. eye examinations by an optometrist, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses;
  2. eyeglasses and contact lenses that are necessary for the correction of vision and are prescribed by an ophthalmologist or optometrist, and repairs to them, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses;
  3. elective laser eye surgery to correct vision, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses per covered person under the Plan, and not per eye or per procedure. The surgery must be performed by an ophthalmologist. However, a physician’s prescription (referral) is not required by the Plan. Expenses incurred for cataract surgery are not eligible under this benefit;
  4. the initial purchase of either intraocular lenses, eyeglasses or contact lenses if required as a direct result of surgery or an accident where the purchase is made within six (6) months of such accident or surgery. This benefit is not subject to any limits other than reasonable and customary. The six (6) month time limit may be extended if, as determined by the Plan Administrator, the purchase could not have been made within the time frame specified;
  5. artificial eyes and replacements thereof but not within:
    1. 60 months of the last purchase in the case of a member or dependant over 21 years of age, or
    2. 12 months of the last purchase in the case of a dependant 21 years of age or less,

unless medically proven that growth or shrinkage of surrounding tissue requires replacement of the existing prosthesis.

Exclusions

6.3.2 No benefit is payable for:

  1. eye-related procedures which use lasers but where the laser does not reshape the cornea with the goal of correcting common vision problems;
  2. expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions.

6.4  Medical Practitioners Benefit (For All Members)

6.4.1 Eligible expenses for the services of a medical practitioner include only those services that are within their area of expertise and require the skills and qualifications of such a medical practitioner. In addition, in accordance with provincial or territorial regulations, the medical practitioner must be registered, licensed, or certified to practice in the jurisdiction where the services are rendered.

6.4.2 Eligible expenses are the reasonable and customary charges for:

  1. physician's services and laboratory services where such services are not eligible for reimbursement under the participant's provincial/territorial health insurance plan, but where such services would be eligible for reimbursement under one or more other provincial/territorial health insurance plans.
    1. Laboratory services include those services which when ordered by and performed under the direction of a physician provide information used in the diagnosis or treatment of disease or injury. Services include, but are not limited to, blood or other body fluid analysis, clinical pathology radiological procedures, ultrasounds, etc.
    2. Where only one province/territory provides reimbursement for a particular service, and that province/territory discontinues the coverage, the issue shall be subject to review by the Partners Committee as to whether coverage will also be discontinued under the Plan. Claims for such services, following cessation of provincial/territorial coverage, shall be held by the Plan Administrator pending the decision of the Partners Committee.
    3. Where a province/territory begins reimbursement for a particular service, claims for the service shall be held by the Plan Administrator pending a review by the Partners Committee as to whether the service should be covered in the other provinces and territories;
  2. medically necessary private duty and visiting nursing services provided by a nurse graduated from a recognized school of nursing where such services are prescribed by a physician or nurse practitioner (if authorized by provincial/territorial legislation), and are rendered in the patient's private residence, subject to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses. The prescription is valid for one year unless otherwise advised by the Plan Administrator;
  3. the services of the following practitioners, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses for each practitioner:
    1. acupuncturist,
    2. chiropractor,
    3. dietitian,
    4. electrologist or physician when performing electrolysis treatments, limited to:
      • treatment for the permanent removal of excessive hair from exposed areas of the face and neck when the patient suffers from severe emotional trauma as a result of this condition, and,
      • in the case where the services are performed by an electrologist, a psychiatrist or psychologist prescription is required to certify that the patient suffers from severe emotional trauma as a result of this condition;
      • a physician’s/nurse practitioner’s prescription is required and is valid for three years. A prescription is not required if the patient is undergoing electrolysis in relation to gender affirmation,
    5. lactation consultant,
    6. massage therapist,
    7. naturopath,
    8. occupational therapist,
    9. osteopath,
    10. physiotherapist,
    11. podiatrist and chiropodist, including foot care services rendered by a nurse at a community nursing station,
    12. psychologist, psychotherapist/registered counsellor, and social worker,
    13. speech language pathologist and audiologist;
  4. utilization fees for paramedical services which are imposed by the government under the provincial/territorial health insurance plan in the person's province/territory of residence, where the law permits a person to be reimbursed for such charges;
  5. Prostatic Specific Antigen (PSA) test used for monitoring following the detection of cancer.

Exclusions

6.4.3 No benefit is payable for:

  1. expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions;
  2. expenses for surgical supplies and diagnostic aids;
  3. Prostatic Specific Antigen (PSA) test used for screening purposes, and Prostate Cancer Detection (PCA) PCA3 urine test;
  4. expenses incurred for nursing services provided by salaried employees of a facility where the member or dependant resides in such facility.

6.5  Miscellaneous Expense Benefit (For All Members)

6.5.1 To be eligible, the expenses must be:

  1. reasonable and customary charges; and
  2. prescribed by a physician or nurse practitioner (if authorized by provincial/territorial legislation), unless otherwise specified.

6.5.2 Eligible expenses are:

  1. licensed emergency ground ambulance services to the nearest hospital equipped to provide the required treatment when the physical condition of the patient prevents the use of another means of transportation, where medically necessary;
  2. emergency air ambulance service to the nearest hospital equipped to provide the required treatment when the physical condition of the patient prevents the use of another means of transportation;
  3. orthopaedic shoes, which are an integral part of a brace or are specially constructed for the patient, including modifications to such shoes, provided the shoes or modification is prescribed in writing by a physician, nurse practitioner (if authorized by provincial/territorial legislation), or podiatrist, limited to a maximum total eligible expense in any one calendar year as specified in the Summary of Maximum Eligible Expenses; the prescription is valid for one (1) year;
  4. orthotics and repairs to them, prescribed in writing by a physician, nurse practitioner (if authorized by provincial/territorial legislation), or podiatrist, and dispensed by an eligible provider, as determined by the Plan Administrator, limited to one pair in a calendar year; the prescription is valid for three (3) years;
  5. hearing aids and related expenses:
    1. hearing aids and repairs to them, limited to the maximum eligible expense equal to the lesser of:
      • cost less the cost of all eligible hearing aid expenses incurred and claimed in the previous 5 years, and
      • subject to the maximum specified in the Summary of Maximum Eligible Expenses,
    2. batteries for hearing aids, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses,
    3. the initial purchase of hearing aids if required as a direct result of surgery or an accident where the purchase is made within six (6) months of such accident or surgery. This benefit is not subject to any limits other than reasonable and customary. The six (6)-month time limit may be extended if, as determined by the Plan Administrator, the purchase could not have been made within the time frame specified;
  6. trusses, crutches, splints, casts and cervical collars;
  7. braces, including repairs, which contain either metal or hard plastic or other rigid materials that, in the opinion of the Plan Administrator, provide a comparable level of support, excluding dental braces and braces used primarily for athletic use;
  8. orthopaedic brassieres, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses;
  9. breast prosthesis following mastectomy and a replacement provided 24 months have elapsed since the last purchase;
  10. wigs, when the patient is suffering from total hair loss as the result of an illness, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses;
  11. colostomy, ileostomy and tracheostomy supplies;
  12. catheters and drainage bags for incontinent, paraplegic or quadriplegic patients;
  13. temporary artificial limbs;
  14. permanent artificial limbs, to replace temporary artificial limbs, and replacements thereof but not within:
    1. 60 months of the last purchase in the case of a member or dependant over 21 years of age, or
    2. 12 months of the last purchase in the case of a dependant 21 years of age or less,
    unless medically proven that growth or shrinkage of surrounding tissue requires replacement of the existing prosthesis;
  15. oxygen and its administration;
  16. diabetes management, limited to:
    1. diabetic testing supplies, used for the treatment of diabetes, including needles, syringes, and chemical diagnostic aids, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses. Except needles and syringes are not eligible for the 36-month period following the date of purchase of an insulin jet injector device;
    2. one insulin jet injector device for insulin dependent diabetics, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses;
    3. insulin pumps and associated equipment, excluding repair or replacement during the 60-month period following the date of purchase of such equipment;
    4. diabetic monitors, used for the treatment of diabetes, excluding repair or replacement during the 60-month period following the date of purchase of such equipment. Limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses including:
      • flash glucose monitor,
      • standard blood glucose monitor device, and
      • continuous glucose monitor, for type 1 diabetics only, and;
    5. continuous glucose monitor supplies, for type 1 diabetics only, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses;
  17. bandages and surgical dressings required for the treatment of an open wound or ulcer;
  18. elasticized support stockings manufactured to individual patient specifications or having a minimum compression of 30 millimetres;
  19. elasticized apparel for burn victims;
  20. penile prosthesis implants, excluding those eligible under the Gender Affirmation Surgery Benefit;
  21. needles and syringes for the administration of eligible injectable drugs, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses. A physician’s or nurse practitioner’s prescription is required and is valid for three (3) years;
  22. injectable lubricants for joint pain and arthritis (viscosupplement injections), limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses. A physician’s or nurse practitioner’s prescription is required for each injection site and is valid for three (3) years;
  23. gender affirmation: includes 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. Expenses are limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses;
  24. rental or purchase, at the Plan Administrator's option, of cost-effective durable equipment that is:
    1. manufactured specifically for medical use,
    2. for use in the patient's private residence, unless otherwise specified,
    3. approved by the Plan Administrator for cost effectiveness and clinical value,
    4. designated as medically necessary, and
    5. used either for: care. This includes only:
      • devices for physical movement including:
        • lifts or hoists to transfer an individual in and out of bed or in and out of the bathroom - limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible lift/hoist repairs incurred prior to purchase,
        • walkers - limited to one every five (5) years and a maximum eligible expense equal to cost less all eligible walker repair expenses incurred during the previous five (5) years, not limited to use in private residence,
        • wheelchairs - limited to one every five (5) years and a maximum eligible expense equal to cost less all eligible wheelchair repairs incurred during the previous five (5) years; not limited to use in private residence.
          • Replacement of wheelchairs within the five (5) year limit shall be permitted when a patient’s medical condition changes and warrants a different type of chair. Reimbursement will be for the amount of the new chair less the amount reimbursed for the previously claimed chair.
      • devices for support and resting such as:
        • hospital beds - limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible hospital bed repairs incurred prior to purchase,
        • therapeutic mattresses - limited to one every five (5) years and a maximum eligible expense equal to cost less all eligible therapeutic mattress repairs incurred during the previous five (5) years;
        • wheelchair cushions - limited to one every 12 months and a maximum eligible expense of cost less all eligible wheelchair cushion repairs incurred during the previous 12 months,
      • devices for monitoring such as:
        • apnea monitors – limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible apnea monitor repairs incurred prior to purchase,
        • blood pressure monitors– limited to one every five (5) years and a maximum eligible expense equal to cost less all eligible blood pressure monitor repairs incurred during the previous five (5) years,
        • enuresis monitors – limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible enuresis monitor repairs incurred prior to purchase,
        • oxygen saturation meters – limited to one every five (5) years and a maximum eligible expense equal to cost less all eligible oxygen saturation meter repairs incurred during the previous five (5) years,
        • pulse oximeters – limited to one every five (5) years and a maximum eligible expense equal to cost less all eligible pulse oximeter repairs incurred during the previous five (5) years,
        • saturometers – limited to one every five (5) years and a maximum eligible expense equal to cost less all eligible saturometer repairs incurred during the previous five (5) years,
        • coagulation monitors – limited to one every five (5) years and a maximum eligible expense equal to cost less all eligible coagulation monitor repairs incurred during the previous five (5) years, and
        • heart monitors – limited to one every five (5) years and a maximum eligible expense equal to cost less all eligible heart monitor repairs incurred during the previous five (5) years,
    6. for treatment including, but not limited to:
      • devices for mechanical and therapeutic support such as:
        • extremity pumps (lymphapress) - limited to one in a lifetime and an eligible expense equal to cost less all eligible extremity pump repairs incurred prior to purchase;
        • infusion pumps - limited to one every five (5) years and a maximum eligible expense equal to cost less all eligible infusion pump repairs incurred during the previous five (5) years,
        • traction kits - limited to one in a Lifetime and a maximum eligible expense equal to cost less all eligible traction kit repairs incurred prior to purchase,
        • transcutaneous electric stimulators (TENS) - limited to one every 10 years and a maximum eligible expense equal to cost less all eligible TENS repairs incurred during the previous 10 years,
      • devices for aerotherapeutic support such as:
        • CPAP's, BiPAP's or related dental appliances (where a CPAP or BiPAP cannot be tolerated) - limited to one every five (5) years and a maximum eligible expense equal to cost less all eligible rentals and purchases of CPAP, BiPAP or dental appliance incurred during the previous five (5) years,
          • repairs, servicing, and replacement parts for eligible aerotherapeutic devices, such as tubing, filters, cushions, and masks, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses, excluding warranties and cleaning solutions and supplies,
        • compressors - limited to one every five (5) years and a maximum eligible expense equal to cost less all eligible compressor repairs incurred during the previous five (5) years,
        • nebulizer – limited to one every five (5) years and a maximum eligible expense equal to cost less all eligible nebulizer repairs incurred during the previous five (5) years.
    7. Reimbursement related to durable equipment will be limited to the cost of non-motorized equipment unless medically proven that the patient requires motorized equipment.

Exclusions

6.5.3 No benefit is payable for:

  1. expenses for items purchased primarily for athletic use;
  2. expenses for ambulance services for a medical evacuation which are eligible under the Out-of-Province Benefit;
  3. expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions;
  4. durable equipment that is:
    1. an accessory to an eligible device,
    2. a modification to the patient's home (bar, ramp, mat, elevator, etc.),
    3. used for diagnostic or monitoring purposes except as specifically provided under eligible expenses,
    4. an implant, except as specifically provided under eligible expenses, and those eligible under the Gender Affirmation Benefit,
    5. bathroom safety equipment, or
    6. an air conditioner;
  5. ongoing supplies associated with durable equipment, except as specifically provided under eligible expenses;
  6. durable equipment that is used to prevent illness, disease or injury;
  7. the use of a device for a treatment which, in the Plan Administrator's opinion, is considered to be clinically experimental;
  8. the portion of charges which are payable under a provincial/territorial health insurance plan, or any provincially/territorially sponsored program whether or not the participant is participating in the plan or program.

6.6  Dental Benefit (For All Members)

Lower Cost Alternative

6.6.1 When two or more courses of treatment for oral procedure or accidental injury are considered appropriate, the Plan will pay for the lesser of the two treatments.

6.6.2 Eligible expenses mean the reasonable and customary charges for the following services and oral surgical procedures performed by a dentist.

Accidental Injury

6.6.3 The services of a dental surgeon, and charges for dental prosthesis, required for the treatment of a fractured jaw or for the treatment of accidental injuries to natural teeth if the fracture or injury was caused by external, violent and accidental injury or blow other than an accident associated with normal acts such as cleaning, chewing and eating, provided the treatment occurred within 12 months following the accident or, in the case of a dependant child under 17 years of age, before attaining 18 years of age. A physician's prescription is not required. This time limit may be extended if, as determined by the Plan Administrator, the treatment could not have been rendered within the time frame specified.

6.6.4 If a member is covered under the Public Service Dental Plan, the Pensioner Dental Services Plan, the RCMP Dependants Dental Care Plan, or the CAF Dependants Dental Care Plan, claims for expenses for accidental injury should first be submitted to the PSHCP.

Oral Surgical Procedures

6.6.5 Refer to the following:

  1. cysts, lesions, abscesses
    1. biopsy
      • soft tissue lesion,
      • incision,
      • excision,
      • hard tissue lesion,
    2. excision of cysts,
    3. excision of benign lesion,
    4. excision of ranula,
    5. incision and drainage
      • intra oral - soft tissue,
      • intra osseous (into bone),
    6. periodontal abscess
      • incision and drainage;
  2. gingival and alveolar procedures
    1. alveoplasty,
    2. flap approach with curettage,
    3. flap approach with osteoplasty,
    4. flap approach with curettage and osteoplasty,
    5. gingival curettage,
    6. gingivectomy with or without curettage,
    7. gingivoplasty;
  3. removal of teeth or roots
    1. removal of impacted teeth,
    2. removal of root or foreign body from maxillary antrum,
    3. root resection (apiectomy or apicoectomy)
      • anterior teeth,
      • bicuspids,
      • molars;
  4. fractures and dislocations
    1. dislocation - temporo-mandibular joint (or jaw)
      • closed reduction,
      • open reduction,
    2. fractures - mandible
      • no reduction,
      • closed reduction,
      • open reduction,
    3. fractures - maxillar or malar
      • no reduction,
      • closed reduction,
      • open reduction,
      • open reduction (complicated);
  5. other procedures
    1. avulsion of nerve - supra or infra-orbital,
    2. frenectomy - labial or buccal (lip or cheek),
    3. lingual (tongue),
    4. repair of antro - oral fistula,
    5. sialolithotomy - simple,
    6. sialolithotomy - complicated,
    7. sulcus deepening, ridge reconstruction,
    8. treatment of traumatic injuries
      • repair of soft tissue lacerations,
      • debridement, repair, suturing,
    9. torus (bone biopsy).

6.6.6 If a member is covered under the Public Service Dental Care Plan, the Pensioner Dental Services Plan, the RCMP Dependants Dental Care Plan, or the CAF Dependants Dental Care Plan, claims for expenses for oral surgery should first be submitted to that plan. Any amount not covered by that plan may be submitted to the PSHCP.

Exclusions

6.6.7 No benefit is payable for:

  1. expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions;
  2. dental expenses, except those specifically provided under Eligible Expenses for treatment of accidental injuries to natural teeth and oral surgical procedures.

6.7  Out-of-Province Benefit (For Members with Supplementary Coverage)

6.7.1 The Out-of-Province Benefit consists of:

  1. Emergency Benefit While Travelling;
  2. Emergency Travel Assistance Services;
  3. Referral Benefit.

Emergency Benefit While Travelling

6.7.2 The PSHCP covers each participant for up to $1,000,000 (Canadian) in eligible medical expenses incurred as a result of an emergency while travelling on vacation or on business.

6.7.3 Eligible expenses mean the reasonable and customary charges in excess of the amount payable by a provincial/territorial health insurance plan, if they are required for emergency treatment of an injury or disease which occurs on or after the date of departure from the province/territory of residence. Coverage is limited to 40 consecutive days, excluding any time out of the province for official travel status.

6.7.4 Eligible expenses are charges for:

  1. public ward accommodation and auxiliary hospital services in a general hospital;
  2. services of a physician;
  3. one-way economy return airfare, or other means of transportation when air travel is not possible, for the patient's return to their province/territory of residence. The fare for a professional attendant accompanying the participant is also included where medically required;
  4. medical evacuation, which may include ambulance services, when suitable care, as determined by the Plan Administrator, is not available in the area where the emergency occurred;
  5. family assistance benefits up to a combined maximum of $5,000 for any one travel emergency, as follows:
    1. the maximum payable for dependant children under age 16 who are left unattended because the participant or the participant's covered spouse or common-law partner is hospitalized and an escort (if necessary) is the cost of economy fare for return transportation,
    2. return airfare, or other means of transportation when air travel is not possible, if a family member is hospitalized and as a result the family members are unable to return home on the originally scheduled travel, and must purchase new return tickets. The extra cost of the return fare is payable, to a maximum of the cost of economy fare,
    3. a visit of a relative if the family member is hospitalized for more than seven (7) days while travelling alone. This includes economy return airfare, or other means of transportation when air travel is not possible, and meals and accommodations in commercial lodging to a combined maximum of $200 per day, for a spouse or common-law partner, parent, child, brother or sister. This benefit also covers expenses incurred if it is necessary to identify a deceased family member prior to release of the body,
    4. meals and accommodations in commercial lodging if the participant or a covered dependant’s trip is extended beyond the originally scheduled return date due to hospitalization of a family member, or physician-imposed flight restrictions. The additional expenses incurred by accompanying family members for accommodations and meals are provided to a combined maximum of $200 per day;
  6. return of the deceased in the event of death of a family member. The necessary authorizations will be obtained, and arrangements made, for the return of the deceased to the province/territory of residence. The maximum payable for the preparation and return of the deceased is $3,000.

Emergency Travel Assistance Services

6.7.5 The PSHCP provides a toll-free number which gives participants 24 hour access to a world-wide assistance network. The network will provide:

  1. transportation arrangements to the nearest hospital that provides the appropriate care or back to Canada;
  2. medical referrals, consultation and monitoring;
  3. legal referrals;
  4. a telephone interpretation service;
  5. a message service for family and business associates; messages will be held for up to 15 days;
  6. advance payment on behalf of the participant or a covered dependant for the payment of hospital and medical expenses.

6.7.6 To arrange for advance payment of hospital and medical expenses, the participant must sign an authorization form allowing the Plan Administrator to recover payment from the provincial/territorial health insurance plan. The participant must reimburse the Plan Administrator for any payment made on their behalf which is in excess of the amount eligible for reimbursement under the provincial/territorial health insurance plan and this Plan.

6.7.7 Assistance services are not available in countries of political unrest. The list of countries, as maintained by the Plan Administrator, will change according to world conditions.

6.7.8 Neither the Plan Administrator nor the company providing the assistance network is responsible for the availability, quality or result of the medical treatment received by the participant or for the failure to obtain medical treatment.

Official Travel Status

6.7.9 Employees required to travel on “official travel status” for government business are covered under the Emergency Benefit While Travelling and the Emergency Travel Assistance Services during the entire period of “official travel status”. Although there is no time limit to be on “official travel status”, the $1,000,000 (Canadian) benefit coverage limit still applies.

Referral Benefit

6.7.10 The following items of expense are eligible for reimbursement under the PSHCP provided that the services are:

  1. performed when the participant physically leaves the province/territory of residence;
  2. following a written referral by the attending physician or nurse practitioner in the province/territory of residence;
  3. for a service that is not offered in the province/territory of residence.

6.7.11 Eligible expenses under this benefit will be limited to the reasonable and customary charges in excess of the amount payable by a provincial/territorial health insurance plan and to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses for:

  1. public ward accommodation and auxiliary hospital services in a general hospital;
  2. services of a physician or surgeon;
  3. laboratory services including those services which when ordered by and performed under the direction of a physician or nurse practitioner, provide information used in the diagnosis or treatment of disease or injury. Services include, but are not limited to, blood or other body fluid analysis, clinical pathology, radiological procedures, ultrasounds, etc.

Exclusions

6.7.12 No benefit is payable for:

  1. 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;
  2. expenses incurred by a participant who is temporarily or permanently residing outside Canada;
  3. expenses for the regular treatment of an injury or disease which existed prior to the participant's departure from their province/territory of residence;
  4. expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions.
Index