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Frequently Asked Questions - Public Service Health Care Plan Benefit Card
The following frequently asked questions provide information regarding:
Positive Enrolment
- What do I need to do to get a Public Service Health Care Plan benefit card?
- When did the card take effect?
- What is the advantage to using the card?
- Do all plan members have to complete positive enrolment? Why?
- What happens if I don't enrol myself or my dependants? Will it affect my paper claims?
- I did not receive an enrolment package. How can I enrol?
- I completed positive enrolment, but I haven't received my card yet. What should I do?
- My spouse is working overseas and we did not receive information about positive enrolment or the Public Service Health Care Plan benefit card.
- I gave my consent on the positive enrolment form. With whom will Sun Life share my personal information?
1. What do I need to do to get a Public Service Health Care Plan benefit card?
You must complete positive enrolment. This entails providing information to Sun Life about yourself, your spouse/common-law partner and each eligible child, including full name, address, gender and age, and whether you or any of your dependants have coverage under another group health care plan.
Those already registered as a user on the Sun Life Plan Member Services Web site can enrol online using their access ID and password.
Those not yet registered as a user on the Sun Life Plan Member Services Web site can register as a user now, then enrol online.
If you are a new plan member, go to www.sunlife.ca/newmember_pshcp to complete positive enrolment.
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, 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.
New plan members: 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.
2. When did the card take effect?
Pharmacies in Canada began accepting the card as of November 1, 2010.
3. What is the advantage to using the 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.
4. Do all plan members have to complete positive enrolment? Why?
Yes. All plan members must enrol. As of November 1, 2010, claims are not processed until members have completed positive enrolment.
In order to appropriately administer Canada's largest employer-sponsored health care plan, Sun Life needs accurate electronic information about members and their eligible dependants.
In addition, through positive enrolment, you provide a one-time consent for the use of your personal information to process benefits and administer the plan.
5. What happens if I don't enrol myself or my dependants? Will it affect my paper claims?
As of November 1, 2010, claims are not 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.
6. I did not receive an enrolment package. How can I enrol?
If you are registered as a user on the Sun Life Plan Member Services Web site, you can complete positive enrolment online using your access ID and password.
If you are not yet registered as a user on the Sun Life Plan Member Services Web site, either register as a user now, then enrol online or call 1-888-757-7427 (toll free from anywhere in North America) or, in the National Capital Region, 613-247-5100, Monday to Friday, 6:30 a.m. to 8:00 p.m. EST.
7. I completed positive enrolment, but I haven't received my card yet. What should I do?
If you completed positive enrolment using Positive Enrolment Online, you can print your benefit card as soon as you receive confirmation that your enrolment has been validated.
If you are a new plan member, it can take up to six weeks for your eligibility information to be received by Sun Life and your benefit card produced, if you requested a plastic one. If you have not received your card within that timeframe, 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).
8. My spouse is working overseas and we did not receive information about positive enrolment or the Public Service Health Care Plan benefit card.
Sun Life will provide special assistance to all members posted outside of Canada and their families, to ensure that they have the necessary information to enrol. Sun Life will manage these cases individually to ensure minimal disruption to claims reimbursements.
You can still choose to receive a benefit card; however, it is only valid to purchase eligible prescriptions and medical supplies in pharmacies in Canada.
Even if you are not using the benefit card, you must complete positive enrolment to have your claims processed. For more information, 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).
9. 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 benefits 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.
Claims
- I received my card. Does it need to be activated?
- When can I start using my card?
- Does the benefit card change the practice of "assigning payment" to a pharmacy?
- What happens if my pharmacy does not accept electronic claims processing?
- Can members use the benefit card for claims other than eligible drugs and medical supplies they obtain from pharmacies?
- Why is my paper claim form different?
- Why are some of my prescription drug claims being denied when I use my Public Service Health Care Plan benefit card?
- What if I don't want to use the card? How will I submit claims?
1. I received my card. Does it need to be activated?
No, it does not need to be activated. The Public Service Health Care Plan benefit card is not like a debit or credit card. There is no personal information encoded on the card. What is printed on it is for information only. The Public Service Health Care Plan contract number and your certificate number allow pharmacists to electronically process eligible expenses through their system. In addition, the card provides telephone numbers you may need in case of a medical emergency outside Canada or to contact Sun Life's call centre.
To buy eligible prescription drugs and medical supplies, just present the card to your pharmacist with your prescription.
2. When can I start using my card?
You can use the card immediately.
3. Does the benefit card change the practice of "assigning payment" to a pharmacy?
Before November 1, 2010, the Public Service Health Care Plan allowed members to assign payment for their prescriptions drugs directly to a pharmacy; members would pay their share of the cost and the pharmacist would bill Sun Life directly for the remainder.
Since the benefit card enables the processing of drug claims instantaneously at the majority of pharmacies in Canada, assignment of prescription drug benefits is no longer necessary.
4. What happens if my pharmacy does not accept electronic claims processing?
Once you have completed positive enrolment, you can still pay for eligible expenses up front and submit a paper claim to Sun Life.
However, you must still complete positive enrolment before any claims are processed.
5. Can members use the benefit card for claims other than eligible drugs and medical supplies they obtain from pharmacies?
No. The benefit card enables real time electronic processing of claims for eligible drugs and medical supplies only.
Claims for all other benefits continue to be processed the way they have always been, by way of a paper claim form to Sun Life with receipts attached.
6. Why is my paper claim form different?
With the implementation of the benefit card, the claim form has been revised. You still need to complete all the sections and sign and date the form to submit your claims this way.
You can now have your spouse/common-law partner co-sign your claim form to automatically coordinate benefit between your two certificate numbers if you are both Public Service Health Care Plan (PSHCP) members or between the PSHCP and another plan that Sun Life administers.
7. Why are some of my prescription drug claims being denied when I use my Public Service Health Care Plan benefit card?
The benefit card has brought in improvements in the way prescription drugs and certain medical supplies are processed under the Public Service Health Care Plan to enhance your health and safety and that of your eligible dependants.
When prescription drugs are dispensed, an automatic drug utilization review helps the pharmacist ensure that medication is dispensed safely and after the allowable refill date.
For more information, 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).
8. What if I don't want to use the card? How will I submit claims?
Once you have completed positive enrolment, you can still pay for eligible expenses up front and submit a paper claim to Sun Life.
However, you must still complete positive enrolment before any claims are processed.
Dependants
- What does "eligible dependant" mean?
- I requested a card for each of my dependants but the cards are all in my name. Why?
1. What does "eligible dependant" mean?
Under the terms of the Public Service Health Care Plan, your spouse, your dependant child or a dependant child of your spouse may be eligible to participate under the plan as long as you have family coverage and the person meets the plan's definitions. These definitions are in the Public Service Health Care Plan Document on the National Joint Council Web site, as well as on the Public Service Health Care Plan Administration Authority's Web site.
2. 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. The plan relationship is and always has been with the member; therefore claims for reimbursement of benefits for dependants have always required the signature of the member. The introduction of the new PSHCP benefit card does not in any way change the plan's relationship with members or their dependants. The member may choose to receive additional cards as a convenience, so that the member's spouse/common-law partner and dependant children over age 18 may use the card to process pharmacy claims electronically, without the member being present. The card, however, is issued in the plan member's name.
Drugs and Coverage
- What is a generic drug?
- I usually get a brand name drug when I fill my prescription. Why did my pharmacist give me a different medication?
- What if I still want a brand name drug?
- Why do I have to provide proof of provincial coverage?
- Why is there a day-supply limit on some of my prescriptions?
- 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?
- I submitted a paper claim for my pharmacy purchase; why was my reimbursement reduced?
1. What is a generic drug?
Generic drug is the term used for a product that contains the same medicinal ingredients as its corresponding brand name drug. Use of generic equivalent drugs is widespread in Canada. Health Canada approves all generic drugs for safety, effectiveness and quality, using the same standards for generic-equivalent medication as for the brand name drug.
2. 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.
3. 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.
4. Why do I have to provide proof of provincial coverage?
The Public Service Health Care Plan supplements provincial and territorial health insurance plans for members and their dependents residing in Canada. When members use the benefit card to pay for a prescription, they are assessed against their provincial or territorial supplementary drug plan. With the implementation of the benefit card, we are able to exercise greater care to ensure that the plan only pays for eligible prescriptions, and that provincial coverage pays first, where applicable.
Some members have had their claims denied because the annual dollar threshold in certain provinces has already been surpassed.
When members provide proof of provincial coverage, the amount not paid by the province can be submitted to Sun Life for the member's supplementary benefit.
For more information, 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).
For more information on provincial/territorial health coverage, visit the Health Canada Web site.
5. Why is there a day-supply limit on some of my prescriptions?
The Public Service Health Care Plan (PSHCP) provides coverage for eligible prescription drugs and medical supplies through the new benefit card.
If your doctor has prescribed a medication for an extended period, you can receive up to a 100-day supply at a time.
If you will be travelling and need more than a three-month supply, contact the Sun Life
The Sun Life
6. 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.
7. I submitted a paper claim for my pharmacy purchase; why was my reimbursement reduced?
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 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.
Lost or Stolen Benefit Cards
- 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?
- Is there a fee to replace lost cards or to order additional cards for eligible dependants?
1. 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).Only a plan member and those dependants the plan member reports as dependants during the positive enrolment process will be eligible to use the card. All claims require a valid prescription in the name of the patient and anybody who presents such a prescription along with a lost or stolen Public Service Health Care Plan benefit card will have their claim declined at the pharmacy.
2. Is there a fee to replace lost cards or to order additional cards for eligible dependants?
There is no fee to obtain a replacement or additional card. 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).
