Health Care Plan
On July 1, 2023, the Public Service Health Care Plan will transition to Canada Life. Some of the changes will impact pharmacies and may generate questions by plan members at the pharmacy counter. The following provides an overview of our efforts to address the changes and provides some potential speaking points you can use in explaining the changes to your patients.
Over the past several months, CPhA has met with political and department officials from Treasury Board, as well representatives from Canada Life and some of the unions who negotiated the new agreement to raise concerns about the dispensing fee caps and frequency limits. The changes are a result of negotiations between the federal government and 17 unions and as such are unlikely to change in the immediate future.
PSHCP Forms (including the Dispense Fee Frequency Limit Exception form) are now available on the Canada Life website.
$8 Fee Cap
Effective July 1, 2023, the PSHCP will reimburse up to a maximum of $8 for the pharmacy dispensing fee.
- The dispensing fee cap will not apply to biologic or compound drugs.
- Exceptions may apply to some provinces/territories due to pharmacy regulations.
- Canada Life has confirmed that pharmacies will be able to charge patients the difference if greater than the $8 cap.
Subject to any applicable laws, regulations and/or regulatory requirements, pharmacies may charge whatever dispensing fee they determine is appropriate, which may be greater than, equal to, or lower than $8. If you opt to charge a dispensing fee that is greater than the maximum reimbursable amount under the PSHCP, the following speaking points can be used to help explain the changes to your patients:
- The pharmacy has not increased the dispensing fee [if applicable]. The insurance company and your employer have decided to cap the coverage of the dispensing fee to $8.
- Our dispensing fee is posted publicly [if applicable] and covers many activities that the pharmacy does to make sure that you are getting the right drug and dosage and that it does not interact with other medications. We also have to enter data to make sure your medication profile is complete and we submit your drug claim on your behalf.
- We have been told the changes were made to encourage cost sharing between the plan sponsor (the federal government) and plan members (you) as well as to expand benefits for other health care services. If you are concerned about this, we encourage you to reach out to Canada Life and your employer.
Atlantic Dispense Fee
The provider agreement with TELUS Health that states that differences in adjudicated prices on claims can only be passed along to the cardholder under the following circumstances:
- Difference between your usual and customary dispensing fee and the maximum dispensing fee paid under the plan (does not apply in New Brunswick, Newfoundland, Nova Scotia and Prince Edward Island).
In New Brunswick, Newfoundland, Nova Scotia and Prince Edward Island, according to Canada Life, pharmacies are only able to charge the difference between the pharmacy usual and customary dispense fee and the TELUS maximum dispense fee in the respective Atlantic province, as per their agreements with TELUS. In the case where the PSHCP that has a dispense fee cap that is lower than the TELUS maximum dispense fee, pharmacies are able to charge PSHCP members the difference between the TELUS maximum dispense fee and the group dispense fee cap of $8.
Effective July 1, 2023, the pharmacy dispensing fee will be reimbursed up to a maximum of five times per year for maintenance drugs. Exceptions will be considered in situations such as:
- Safety concerns with the prescribed drug
- Storage limitations for the prescribed drug (e.g. requiring deep freeze temperatures)
- The prescribed drug’s 3-month supply co-pay is more than $100
Exceptions may apply to some provinces/territories due to pharmacy regulations.
- For any type of exception to the coverage of dispense fee frequency limitation, for example compliance packaging, a form must be submitted to Canada Life for review and approval. The exception form will be available for PSHCP members to complete, with information from their prescriber. If an exception is granted, Canada Life updates the system to allow more than 5 dispense fees per year to be eligible. There is no override at the pharmacy level or code to enter.
We understand that many pharmacists may want to assist their patients in navigating these exemptions, particularly to ensure the best patient outcomes. We also understand that any additional steps can result in increased administrative burden for pharmacy staff and can disincentivize patients from seeking such exemptions. A letter expressing our concerns has been sent to Canada Life, with the goal of removing any unnecessary barriers for access.
The following speaking points can be used to help inform patients about the extra step:
- Compliance packaging which includes blister packs or dosettes can help you adhere to your medication regimens if you take many medications, have a complicated schedule or have difficulties with traditional packaging. Compliance packs are provided on a more regular basis and usually dispensed 1-2 weeks at a time.
- Your new plan only covers five total dispenses, including the dispensing of compliance packs, unless you receive an exemption through your insurer and employer.
- The form you need to complete to receive an exemption is available online through your portal.
- The form is a new requirement put in place by your insurer and employer. If you are already receiving compliance packaging, we may need to temporarily provide traditional dispensing until you receive an exemption from Canada Life or you may need to pay out-of-pocket for dispensing until you receive your exemption.
- Once you have received approval from Canada Life, please let us know and we will quickly resume your usual service.
For more information you can visit the Public Service Health Care Plan Directive.