FAQ

New to the PSHCP

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How can I join the Plan?

Here’s a basic summary of the steps you need to take when you first join the Plan:

1. Apply for PSHCP coverage: Submit a PSHCP application form to Compensation or your pension office. You can also complete the form using Compensation Web Applications if this service is available to you.
   
   Once your application is accepted and processed, you will receive a Certificate Number—this number identifies you as a member of the Plan.
2. Complete Positive Enrolment: Visit Sun Life’s Plan Member Services website at www.sunlife.ca/pshcp and click on “New member to the Plan”. Read the instructions and click on the link to the online form.
   
   Complete all sections of the Positive Enrolment form. You will be asked to enter the Contract Number for the Plan (055555) and your Certificate Number when you begin.
3. Request or print a PSHCP benefit card: When you fill out the Positive Enrolment form, you will be asked if you require a card for yourself and/or your eligible dependants. You will be able to print your card or receive it by mail when your Positive Enrolment has been processed by Sun Life.

See Managing my Plan for more details.

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How can I access my Sun Life online account?

You can register for your online account once your Positive Enrolment information has been processed and validated by Sun Life. Your online account allows you to log onto your personal file using an Access ID and password so that you can keep track of claims you’ve submitted, update your Positive Enrolment information, and register for direct deposit.

How to register for an online account:

1. Go to the Sun Life Plan Member Services website for PSHCP members: www.sunlife.ca/pshcp
2. Click on “Register Now” under the Sign In module.
3. Click “Register-benefits plan” and enter the required information (including the Plan Contract Number and your Certificate Number). When you complete the registration process, you will be provided with an Access ID and your password will be sent to you by mail.
4. After you receive your password in the mail, return to the Member Services website and use your Access ID and password to activate your account.

If you forget your Access ID or password, contact the Sun Life Call Centre.

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Does the Plan pay for all medical expenses?

The short answer is no. The PSHCP is designed to provide supplementary health care coverage for members who have provincial or territorial health insurance and basic health care coverage with supplementary benefits for members who live outside of Canada. Not all medical services and products are eligible under the Plan.

Unless otherwise stated, the Plan will reimburse the member for 80% of the reasonable and customary charges incurred for an eligible service or product up to a certain amount (maximum eligible expense). The remaining 20% of such eligible expenses paid by the member is known as the co-payment.

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Will I get better benefits if I apply for Level III coverage?

When you select Level I, II, or III on your PSHCP application form, you are choosing your level of coverage for the Hospital Provision, which provides reimbursement for hospital accommodation above standard ward charges (i.e. private or semi-private rooms). Level I refers to the lowest daily maximum payable to you, and Level III refers to the highest daily maximum.

You will not receive greater reimbursement on other areas of the Plan when you select a higher level of coverage under the Hospital Provision.

Positive Enrolment

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What is “Positive Enrolment”?

Positive Enrolment is a mandatory part of the registration process where you provide information to Sun Life about yourself, your spouse/common-law partner and each eligible dependant. You will need to provide the full name, address, gender and age of those who will be covered under the Plan. You must also indicate whether you or any of your dependants have coverage under another group health care plan.

Through Positive Enrolment, you provide a one-time consent to Sun Life for the use of your personal information to process your benefits and administer the Plan.

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How do I complete Positive Enrolment?

If you are a new Plan member, go to www.sunlife.ca/newmember_pshcp to complete Positive Enrolment.

Visit Sun Life’s Plan Member Services website at www.sunlife.ca/pshcp and click on “New member to the Plan”. Read the instructions and click on the link to the online form.

If you prefer to complete Positive Enrolment on paper, call the Sun Life Call Centre at 1-888-757-7427 (toll free from anywhere in North America) or, in the National Capital Region at 613-247-5100, Monday to Friday, 6:30 a.m. to 8:00 p.m. EST. Sun Life will then mail the Positive Enrolment Form and instructions to you.

Complete all sections of the Positive Enrolment form. You will be asked to enter the Contract Number for the Plan (055555) and your Certificate Number when you begin.

Sun Life will hold your enrolment until it receives confirmation that you are eligible for Plan coverage. This can take up to six weeks. Once Sun Life receives that confirmation, they will validate your Positive Enrolment information and process any claims you have submitted in the meantime.

If you are not a new member but you need to update your Positive Enrolment information, you can log into your account on the Sun Life Plan Member Services Web site using your Access ID and password to make changes to your Positive Enrolment profile. You can also print the Positive Enrolment Change Form without logging into your account.

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What happens if I don't enrol myself or my dependants? Will it affect my claims?

Claims cannot be processed until you have completed Positive Enrolment. If you submit a claim but have not enrolled, the claim will be put on hold and Sun Life will notify you of the requirement to enrol. Once you enrol, you can return your Claims Statement to Sun Life so that your claim can be processed.

If you do not provide information about your dependants during Positive Enrolment, they will not be covered under the Plan.

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I gave my consent on the Positive Enrolment form. With whom will Sun Life share my personal information?

On the basis of your consent, Sun Life will use your personal information to administer the Plan, and to adjudicate and pay your claims. For example, on occasion, Sun Life may contact a health organization such as a hospital to confirm what type of hospital room you had, or a professional health care provider such as a physiotherapist or pharmacist to verify the service or product they have provided.

Information will be collected and shared only for the purposes outlined in the Public Service Health Care Plan Privacy Statement. Both the Privacy Statement and the consent wording on your enrolment form conform to privacy legislation, the Privacy Act and the Personal Information Protection and Electronic Documents Act (PIPEDA).

PSHCP benefit card

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How do I get a PSHCP benefit card?

First, you must complete Positive Enrolment.

If you complete Positive Enrolment online, you will be asked whether you want to print a PSHCP benefit card or have a plastic card mailed to you. You can request a card for yourself and your eligible dependants over 18 years of age.

Your PSHCP benefit card will be available once your Positive Enrolment information has been validated by Sun Life.

You can also access it anytime through the my Sun Life Mobile application.

If you request a plastic card and do not receive it within six weeks, contact the Sun Life Call Centre from Monday to Friday, 6:30 a.m. to 8:00 p.m. EST in the National Capital Region at 613-247-5100, or 1-888-757-7427 (toll-free from anywhere in North America).

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What is the advantage to using the PSHCP benefit card?

With the benefit card, you and your eligible family members no longer have to pay the full cost of eligible prescription drugs and medical supplies up-front, and then mail in a claim for reimbursement. You only have to pay your share of the cost of each prescription.

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Do I have to use the PSHCP benefit card?

Use of the PSHCP benefit card is optional. You can still pay for eligible expenses up-front and submit a paper claim to Sun Life.

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I submitted a paper/electronic claim for my pharmacy purchase. Why was my reimbursement different from when I use the PSHCP benefit card?

When you use your PSHCP benefit card to purchase a prescription, the pharmacist is required to accept the price paid by Sun Life for eligible prescription drugs and medical supplies. This price file applies across Canada and represents the normal mark-up and cost that the pharmacy can charge.

Because the price file is monitored electronically through the use of the benefit card, if you do not use the card when purchasing your prescription, you may be charged more than the established price file. If this occurs, when you submit your paper or electronic claim to Sun Life, it will be evaluated based on the price file amount and your reimbursement will be reduced.

If you use your PSHCP benefit card for all transactions, you will not have to pay any ineligible amount.

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I received my benefit card. Does it need to be activated?

No, it does not need to be activated.

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When can I start using my benefit card?

You can use the card immediately.

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What happens if my pharmacy does not accept electronic claims processing?

You can still pay for eligible expenses up-front and submit a paper or electronic claim to Sun Life, as long as you have completed Positive Enrolment.

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Can I use the PSHCP benefit card for claims other than eligible drugs and medical supplies from pharmacies?

No. The benefit card enables real-time electronic processing of claims for eligible drugs and certain medical supplies only.

For all other benefits, you must submit a paper claim form to Sun Life with receipts attached or submit an electronic claim on Sun Life's Plan Member Services website or the my Sun Life Mobile application.

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I requested a card for each of my dependants but the cards are all in my name. Why?

The Public Service Health Care Plan (PSHCP) provides coverage for members and their eligible dependants, but the Plan relationship is with the member.

You may choose to receive additional cards as a convenience, so that your spouse/common-law partner and dependant children over the age of 18 may use the card to process their own pharmacy claims electronically. You do not have to be present for your dependants to use the PSHCP benefit card.

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Whom can I contact if the information on my card(s) is not correct? What do I do if my card is lost or stolen?

Contact the Sun Life Call Centre from Monday to Friday, 6:30 a.m. to 8:00 p.m. EST in the National Capital Region at 613-247-5100 or 1-888-757-7427 (toll-free from anywhere in North America) to correct information on your card or request an additional card.

If someone tries to use your card at a pharmacy, their claim will be denied because the name on the prescription does not match the Plan member and dependant information associated with your certificate number. Only Plan members and dependants registered during Positive Enrolment are eligible to use the PSHCP benefit card.

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Is there a fee to replace lost cards or to order additional cards for eligible dependants?

No. Cards are provided free of charge.

Contact the Sun Life Call Centre from Monday to Friday, 6:30 a.m. to 8:00 p.m. EST in the National Capital Region at 613-247-5100 or 1-888-757-7427 (toll free from anywhere in North America) to request an additional card.

Claims

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How do I submit claims to the Plan?

If you have Supplementary Coverage:

• You can pay for services or drugs up-front and submit your receipts to Sun Life along with a PSHCP claim form or submit them electronically on Sun Life's Plan Member Services website or the my Sun Life application.
• You can use the PSHCP benefit card when you buy eligible drugs and medical supplies at a pharmacy. The pharmacist sends the drug claim to Sun Life electronically, and you pay only your portion of the drug cost.

If you have Comprehensive Coverage (i.e. you live outside of Canada):

• You pay for services and drugs up-front and then submit your claim form and receipts to Allianz Global Assistance. The PSHCP benefit card can only be used in Canada.

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How does Sun Life determine the amount paid to the participant?

Sun Life reimburses the member when they receive proof that the Plan participant has incurred an eligible expense. The total expense claimed is adjusted as follows:

1. The maximum eligible expense is applied;
2. The co-payment is subtracted.

Prescriptions

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How long is my prescription valid?

Prescriptions are valid for one year for services of the following medical practitioners:

• Physiotherapist
• Massage therapist
• Speech language pathologist
• Psychologist (or social worker in isolated posts where there are no psychologists)
• Nurse (unless otherwise advised by Sun Life)

Prescriptions are valid for three years for the services of an electrologist.

Prescriptions are valid for three years for orthotics, but one year for orthopaedic shoes.

For drugs, prescriptions are valid for one year.

For other prescriptions, you should contact Sun Life to find out the length of time the prescription is valid.

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What is a generic drug?

A generic drug is a product that contains the same medicinal ingredients as its corresponding brand-name drug. Use of generic drugs is widespread in Canada. Health Canada approves all generic drugs for safety, effectiveness and quality, according to the same standards used to approve brand-name drugs.

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I usually get a brand-name drug when I fill my prescription. Why did my pharmacist give me a different medication?

You can verify with your pharmacist, but it's possible that your pharmacist dispensed a generic drug to replace the brand-name drug your doctor prescribed.

It was decided in 2006 that the Public Service Health Care Plan (PSHCP) would adopt the practise of substitution of generic for brand-name drugs; therefore, the PSHCP reimburses the cost of the lowest-cost equivalent drug, unless your doctor indicates "No substitution" on the prescription.

Not all drugs have a generic equivalent; however, where they do, generics often cost less than the brand-name drug, which results in a lower cost for your 20% share of the prescription. In the case where the brand-name drug is less expensive, the lower cost prescription will be dispensed.

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What if I still want a brand-name drug?

If you and your physician have discussed this issue, and your doctor believes that you need to take the brand-name drug rather than the generic equivalent, your doctor can indicate "No substitution" on your prescription, and the Plan will pay the cost of the brand-name drug.

You always have a choice. If you wish to pay the higher cost of the brand-name drug, you can ask your pharmacist to dispense the brand name. The Plan will pay the cost of the generic equivalent, and your share of the cost will increase.

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Why is there a day-supply limit on some of my prescriptions?

Day-supply limits are standard practice in the pharmacist community. They provide the pharmacist an opportunity to consult with you about your medication and ensure you are taking it properly.

If your doctor has prescribed a medication for an extended period, you can receive up to a 100-day supply (roughly three months) at a time.

If you will be travelling and need more than a three-month supply, contact the Sun Life Call Centre from the National Capital Region 613-247-5100 or toll free from anywhere in North America at 1-888-757-7427. Sun Life will make a notation on your file so that you can purchase an additional 100-day supply with your PSHCP benefit card the next time you visit your pharmacy. This file update can take up to two business days to appear in the pharmacy’s system.

You must notify Sun Life each time you require a supply for more than 100 days.

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Why is my pharmacist requesting a prescription for products I have been buying for years and for which I have been receiving reimbursement under the Plan?

Your pharmacist may request a prescription for products you have been purchasing to ensure that you are under ongoing medical treatment and to ensure the prescription is current.

Because certain products are now being processed electronically, pharmacists may also require a prescription for external audit purposes.