Home » Directives » Public Service Health Care Plan Directive » April 1, 2006 (ARCHIVED) » Extended Health Provision

Extended Health Provision

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.

The Extended Health Provision is comprised of the following benefits:

  • Drug Benefit
  • Vision Care Benefit
  • Medical Practitioners Benefit
  • Miscellaneous Expense Benefit
  • Dental Benefit
  • Out-of-Province Benefit (for members with Supplementary Coverage only)
    • Emergency Benefit While Travelling
    • Emergency Travel Assistance Services
    • Referral Benefit

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 deductible and co-payment except for the Emergency Benefit While Travelling and the Emergency Travel Assistance Services.

Drug Benefit

For: all members

To be eligible, expenses must be:

  • the reasonable and customary charges,
  • prescribed by a physician, dentist, or other qualified health professional if the applicable provincial/territorial legislation permits them to prescribe the drugs, and
  • dispensed by a pharmacist or physician.

Eligible expenses are:

  1. drugs which 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 under Exclusions listed in this section;
  2. life-sustaining drugs which may not legally require a prescription and are identified in Schedule VII of this Plan Document;
  3. 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;
  4. injectable drugs, including allergy serums administered by injection;
  5. compounded prescriptions, regardless of their active ingredients;
  6. 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 are available to the patient;
  7. drug delivery devices to deliver asthma medication, which are integral to the product, and approved by the Administrator;
  8. aerochambers with masks for the delivery of asthma medication;
  9. specialised formulas for infants with a confirmed intolerance to both bovine and soy protein. The attending physician must confirm in writing that the infant cannot tolerate any other formula or feeding substitute;
  10. smoking cessation aids limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses.

Catastrophic Drug Coverage in the Event of High Drug Costs

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 $3,000 in out-of-pocket drug expenses excluding the annual deductible. Eligible drug expenses incurred during the same calendar year in excess of this threshold will then be reimbursed at 100%.

Exclusions

No benefit is payable for:

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

Vision Care Benefit

For: all members

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. the initial purchase of intraocular lenses, eyeglasses or contact lenses if required as a direct result of surgery or an accident where the purchase is made within six months of such accident or surgery. This benefit is not subject to any limits other than reasonable and customary. The six-month time limit may be extended if, as determined by the Administrator, the purchase could not have been made within the time frame specified;
  4. 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

No benefit is payable for:

  1. laser eye surgery to correct vision so that visual aids such as glasses or contact lenses will no longer be required. This would include but not be limited to, procedures such as Eximer Laser, Photo Refractive Keratectomy (PRK), Lasik;
  2. expenses incurred under any of the conditions listed under General Exclusions and Limitations in the Plan Provisions.

Medical Practitioners Benefit

For: all members

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 practise in the jurisdiction where the services are rendered.

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.

    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.

    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 Trustees 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 Administrator pending the decision of the Trustees.

    Where a province/territory begins reimbursement for a particular service, claims for the service shall be held by the Administrator pending a review by the Trustees as to whether the service should be covered in the other provinces and territories.

  2. acupuncture treatments performed by a physician.
  3. medically necessary private duty and visiting nursing services provided by a nurse graduated from a recognised school of nursing where such services are prescribed by a physician 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 Administrator.
  4. the services of the following practitioners, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses for each practitioner:
    1. physiotherapist (the prescription* is valid for one year),
    2. massage therapist (the prescription* is valid for one year),
    3. speech language pathologist (the prescription* is valid for one year),
    4. psychologist (the prescription* is valid for one year),
    5. social worker (Isolated Posts only) (the prescription* is valid for one year),
    6. chiropractor,
    7. osteopath,
    8. naturopath,
    9. podiatrist, or chiropodist, and
    10. 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;
    • the prescription is valid for three years.
    * physician's prescription is required.
  5. utilisation 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.
  6. Prostatic Specific Antigen (PSA) test used for monitoring following the detection of cancer.
  7. services of a social worker in lieu of a psychologist provided that:
    1. a physician's prescription has been issued within one year of the expense being incurred;
    2. the participant resides in an isolated post as specified in Appendix A to the National Joint Council's Isolated Posts and Government Housing Directive; and
    3. no psychologist practises in that Isolated Post.

Exclusions

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.
  4. expenses incurred for nursing services provided by salaried employees of a facility where the member or dependant resides in such facility.

Miscellaneous Expense Benefit

For: all members

To be eligible, the expenses must be:

  • reasonable and customary charges, and
  • prescribed by a physician, unless otherwise specified.

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; (amended June 17, 2004)
  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 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 year;
  4. orthotics and repairs to them, prescribed in writing by a physician or podiatrist, limited to one pair in a calendar year; the prescription is valid for three years;
  5.  
    1. hearing aids and repairs to them, excluding batteries, limited to the maximum eligible expense equal to the lesser of:
      1. cost less the cost of all eligible hearing aid claims made in the previous 5 years and
      2. the maximum specified in the Summary of Maximum Eligible Expenses;
    2. the initial purchase of hearing aids if required as a direct result of surgery or an accident where the purchase is made within six months of such accident or surgery. This benefit is not subject to any limits other than reasonable and customary. The six-month time limit may be extended if, as determined by the 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. needles, syringes, and chemical diagnostic aids for the treatment of diabetes, except needles and syringes are not eligible for the 36 month period following the date of purchase of an insulin jet injector device;
  17. one insulin jet injector device for insulin dependant diabetics, limited to the maximum eligible expense specified in the Summary of Maximum Eligible Expenses;
  18. insulin pumps and associated equipment for insulin dependent diabetics, when prescribed for a patient by a physician associated with a recognised centre for the treatment of diabetes at a university teaching centre in Canada, excluding repair or replacement during the 60 month period following the date of purchase of such equipment;
  19. blood glucose monitors for insulin dependent diabetics, and for non-insulin dependent diabetics if legally blind or colour blind, excluding repair or replacement during the 60 month period following the date of purchase of such equipment;
  20. rental or purchase at the Administrator's option, of cost effective durable equipment
    1. manufactured specifically for medical use,
    2. for use in the patient's private residence,
    3. approved by the Administrator for cost effectiveness and clinical value,
    4. designated as medically necessary, and
    5. used either for care including, but not limited to: 
      1. devices for physical movement such as:
        1. walkers - limited to one every five years and a maximum eligible expense equal to cost less all eligible walker repair expenses incurred during the previous 5 years,
        2. lifts or hoists - limited to one in a lifetime and a maximum eligible expense equal to cost less all eligible lift/hoist repairs incurred prior to purchase,
        3. wheelchairs - limited to one every 5 years and a maximum eligible expense equal to cost less all eligible wheelchair repairs incurred during the previous 5 years;
      2. devices for support and resting such as:
        1. 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,
        2. roho cushions - limited to one every 12 months and a maximum eligible expense of cost less all eligible roho cushion repairs incurred during the previous 12 months,
        3. therapeutic mattresses - limited to one every 5 years and a maximum eligible expense equal to cost less all eligible therapeutic mattress repairs incurred during the previous 5 years;
      3. devices for monitoring such as:
        1. 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,
        2. 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, or
    6. for treatment including, but not limited to:
      1. devices for mechanical and therapeutic support such as:
        1. 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,
        2. 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,
        3. infusion pumps - limited to one every 5 years and a maximum eligible expense equal to cost less all eligible infusion pump repairs incurred during the previous 5 years,
        4. extremity pumps (lymphapress) - limited to one in a lifetime and a eligible expense equal to cost less all eligible extremity pump repairs incurred prior to purchase;
      2. devices for aerotherapeutic support such as:
        1. CPAP's, BiPAP's and related dental appliances (where a CPAP or BiPAP cannot be tolerated) - limited to one every 5 years and a maximum eligible expense equal to cost less all eligible CPAP, BiPAP or dental appliance repairs incurred during the previous 5 years,
        2. compressors - limited to one every 5 years and a maximum eligible expense equal to of cost less all eligible compressor repairs incurred during the previous 5 years,
        3. maximists - limited to one every 5 years and a maximum eligible expense equal to cost less all eligible maximist repairs incurred during the previous 5 years;

          Reimbursement related to durable equipment will be limited to the cost of non-motorised equipment unless medically proven that the patient requires motorised equipment.
  21. bandages and surgical dressings required for the treatment of an open wound or ulcer;
  22. elasticised support stockings manufactured to individual patient specifications or having a minimum compression of 30 millimetres;
  23. elasticised apparel for burn victims;
  24. penile prosthesis implants.

Exclusions

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,
    5. bathroom safety equipment, or
    6. an air conditioner;
  5. ongoing supplies associated with durable equipment;
  6. durable equipment that is used to prevent illness, disease or injury;
  7. the use of a device for a treatment which in the 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.

Dental Benefit

For: all members

Lower Cost Alternative

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.

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

Accidental Injury

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 Administrator, the treatment could not have been rendered within the time frame specified.

If a member is covered under the Public Service Dental Plan, the Pensioner Dental Services Plan, the RCMP Dependants Dental Care Plan, or the CF Dependants Dental Care Plan, claims for expenses for accidental injury should first be submitted to the PSHCP. (amended September 8, 2006)

Oral Surgical Procedures

  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)

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 CF 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. (amended September 8, 2006)

Exclusions

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.

Out-of-Province Benefit

For: members with Supplementary Coverage

The Out-of-Province Benefit consists of:

  • Emergency Benefit While Travelling
  • Emergency Travel Assistance Services
  • Referral Benefit

Emergency Benefit While Travelling

The PSHCP covers each participant for up to $500,000 (Canadian) in eligible medical expenses incurred as a result of an emergency while travelling on vacation or on business.

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 within 40 days from the date of departure from the province/territory of residence.

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 air fare for the patient's return to their province/territory of residence. Air 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 Administrator, is not available in the area where the emergency occurred,
  5. family assistance benefits up to a combined maximum of $2,500 for any one travel emergency, as follows:
    1. the maximum payable for dependent children under age 16 who are left unattended because the participant or the participant's covered spouse is hospitalised and an escort (if necessary) is the cost of economy airfare for return transportation;
    2. return transportation if a family member is hospitalised and as a result the family members are unable to return home on the originally scheduled flight, and must purchase new re­turn tickets. The extra cost of the return airfare is payable, to a maximum of the cost of economy airfare,
    3. a visit of a relative if the family member is hospitalised for more than 7 days while travelling alone. This includes economy airfare, and meals and accommodations to a maximum of $150 per day, for a spouse, 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 if the participant or a covered dependant's trip is extended due to hospitalisation of a family member. The additional expenses incurred by accompanying family members for accommodations and meals are provided to a maximum of $150 per day,
  6. return of the deceased in the event of death of a family member. The necessary authorisations 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

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.

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

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

Neither the 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

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 $500,000 (Canadian) benefit coverage limit still applies.

Referral Benefit

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

  • performed when the participant physically leaves the province/territory of residence;
  • following a written referral by the attending physician in the province/territory of residence;
  • for a service that is not offered in the province/territory of residence.

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:

  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 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

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.
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