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Public Service Health Care Plan Coverage


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#426 idream

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Posted 15 June 2016 - 01:57 PM

I was wondering if anyone knows if there is a limit on fertility drug coverage with Federal government medical benefits (PSHCP) ?

I have never heard of that I am just wondering. I have several thousand worth of drugs covered a few years ago, but have headed into another cycle soon.

 

thanks

idream


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#427 tjluvbug

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Posted 26 June 2016 - 12:59 AM

I was wondering if anyone knows if there is a limit on fertility drug coverage with Federal government medical benefits (PSHCP) ?

I have never heard of that I am just wondering. I have several thousand worth of drugs covered a few years ago, but have headed into another cycle soon.

 

thanks

idream

There is no limit


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#428 grovehill123

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Posted 03 July 2016 - 03:37 PM

So help me here, I'm a provincial worker, with sunlife coverage.  Ontario resident.  Could I have coverage?



#429 CdnHockeyGal

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Posted 03 July 2016 - 06:37 PM

It depends on how your group benefits program was designed. You would have to read your benefits booklet and call your group provider with the DINs to determine if they would be covered.
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#430 outdoorsliving

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Posted 05 December 2016 - 01:25 AM

Still no updates yet?  Anyone contact the Plan Administrators or anything lately?  How frustrating this whole process is.  

 

the PSHCP needs to be updated in general anyways, several things are old.  Do you know if/when it could get re-negotiated?  (However, even with the current government they will probably take more away from our plan if they could.. Considering how they have been at the bargaining table lately and still haven't settled on a new contract).



#431 idream

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Posted 21 December 2016 - 04:49 PM

I am wondering if anyone with the federal government has ever reached the catastrophe level of drug coverage?

 

Meaning that your out of pocket expenses have been more then $3000.00 in a fiscal year (or $15000.00 in total)?

 

I am wondering if fertility drugs are included in that calculation? i could be at half that by the end of January.  gadzooks!!!


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#432 idream

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Posted 21 December 2016 - 04:51 PM

Still no updates yet?  Anyone contact the Plan Administrators or anything lately?  How frustrating this whole process is.  

 

the PSHCP needs to be updated in general anyways, several things are old.  Do you know if/when it could get re-negotiated?  (However, even with the current government they will probably take more away from our plan if they could.. Considering how they have been at the bargaining table lately and still haven't settled on a new contract).

 

Did you know that there is a clause in our benefits that states if something is covered by provincial healthcare in one province but not another then our benefits are supposed to cover it.   Check it out.


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#433 Wen1218

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Posted 23 December 2016 - 10:30 AM

Hello,
 
I am in Ontario and I am a federal employee. I have contacted Sunlife and this is what I got from them:

 

***************

Thank you for contacting Sun Life Financial. I welcome this opportunity to assist you.

 

The Customer Care Centre is currently experiencing higher than anticipated email and secured message volumes, resulting in longer than normal response times. We sincerely apologize for this inconvenience. Under the Public Service Health Care Plan (PSHCP), prescription drugs are eligible, provided they meet plan requirements.

 

To be eligible, the 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. Drugs must legally require a prescription and be identified in the Monographs section of the current Compendium of Pharmaceuticals and Specialties as a narcotic, controlled drug, or requiring a prescription, unless they are otherwise specifically listed as eligible expenses in the plan.

 

The Cetrotide 0.25MG Injection (DIN 02247766), Crinone 8% Vag Gel (DIN 02241013), Gonal-F 5.5MCG Injection (DIN 02248154), Gonal-F 300U/0.5ML Pen (DIN 02270404), Gonal-F 450U/0.75ML Pen (DIN 02270390), Gonal-F 900U/1.5 ML Pen (DIN 02270382), Luveris 75 Units Vial (DIN 02269066) and Serophene 50MG Tablet (DIN 00893722) are all eligible and will be reimbursed at 80 percent of the reasonable and customary charge, provided your coverage is in force at the time the expenses are incurred.

 

This drug can be claimed up to a 100 days’ supply, per claim. If a generic equivalent is available, consideration will be based on the cost of the generic rather than the cost of the brand name. Your pharmacist will be able to tell you if a generic is available. Please note that should your Doctor feel that the generic version of this drug is not suitable to treat your medical needs, he/she may indicate on the prescription that no substitutions are to be made. If this is indicated on the prescription, the pharmacy would be able to override the generic substitution for this drug and we would be able to consider the cost of the brand name medication.

 

Please note that this information is based on your eligibility as of the date of this message. If your coverage terminates, you may no longer be eligible for this type of expense.

 

Should you require further information or clarification, we encourage you to contact us through our Websites (www.sunlife.ca/pshcp or www.sunlife.ca/pdsp) or by telephone at 1-888-757-7427, Monday to Friday, 6:30 a.m. to 8 p.m. (ET).



#434 Wen1218

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Posted 23 December 2016 - 10:33 AM

I also have contacted Sun Life regarding the medication coverage for my second try, and here is what I got from them: 

******

 

Thank you for contacting Sun Life Financial. We welcome this opportunity to assist you.

 

We apologize for the delay in responding to your query. Please be aware that a growing volume of messages received in the past month, over our estimated forecast, has rendered our replying times longer than usual.

 

The eligibility of In vitro fertilization (IVF) procedures is currently under review by the Administrative Authority. A review of this nature can take more than 6 months.

 

However, the Public Service Health Care Plan continues to cover 80% of reasonable and customary charges of eligible prescription drugs prescribed by a qualified health practitioner used in IVF treatment, regardless of the reason for treatment or the number of treatment cycles. Please note that this information is based on your eligibility as of the date of this message.

 

If your coverage terminates, you may no longer be eligible for this type of expense. Should you require further information or clarification, we encourage you to contact us through our Web site at www.sunlife.ca/pshcp or by telephone at 1-888-757-7427, Monday to Friday, 6:30 a.m. to 8:00 p.m. (ET).



#435 outdoorsliving

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Posted 17 January 2017 - 02:11 PM

 

Still no updates yet?  Anyone contact the Plan Administrators or anything lately?  How frustrating this whole process is.  

 

the PSHCP needs to be updated in general anyways, several things are old.  Do you know if/when it could get re-negotiated?  (However, even with the current government they will probably take more away from our plan if they could.. Considering how they have been at the bargaining table lately and still haven't settled on a new contract).

 

Did you know that there is a clause in our benefits that states if something is covered by provincial healthcare in one province but not another then our benefits are supposed to cover it.   Check it out.

 

 

 

Yes this is the part of the section I was looking at and wondering if anyone had news from Sunlife regarding that.  Since Ontario will cover one round of IVF, by that clause in the plan we should be covered too if we live in a different province.  So far what it sounds like Sunlife is putting the claims on hold.

 

I already messaged Sunlife and they told me..

 

"Thank you for contacting Sun Life Financial. I welcome this opportunity to assist you. The Customer Care Centre is currently experiencing higher than anticipated secure messages, resulting in longer than normal response times. I sincerely apologize for this inconvenience.

 

At this time, the PSHCP only provides coverage for IVF services to persons with bi-laterally blocked fallopian tubes. If approved, we allow eligible costs for 3 cycles of invitro fertilization (at 80%). While Sun Life is aware that the province of Ontario has announced changes to its coverage, the PSHCP does not automatically cover the same services. A review is underway, unfortunately we cannot confirm when the review will be completed or when a decision will be made (standard claims turn around time does not apply).

 

The PSHCP continues to cover 80% of reasonable and customary charges of eligible prescription drugs prescribed by a qualified health practitioner used in IVF treatment, regardless of the reason for treatment or the number of treatment cycles. To review the eligibility of this service / expense we require: Medical information that indicates that the patient has complete bilateral tube blockage, an itemized cost breakdown of all lab, physician, and other associated costs. Claims that do not meet the criteria are not automatically rendered ineligible: claims will be held pending the outcome of the review.

 

Please note that this information is based on your eligibility as of the date of this message. If your coverage terminates, you may no longer be eligible for this type of expense. Should you require further information or clarification, we encourage you to contact us through our Websites (www.sunlife.ca/pshcp or www.sunlife.ca/pdsp) or by telephone at 1-888-757-7427, Monday to Friday, 6:30 a.m. to 8 p.m. (ET).

 

Sincerely, Audrey Jamison Customer Care Centre Sun Life Financial Canada"
 

 

However I am still going to send in my claim with that clause and pointing out the coverage in Ontario too and hope for the best.  Expecting it to take a long time though.



#436 deformedswimmers

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Posted 07 March 2017 - 06:33 PM

I searched this topic quickly to see if anyone else is having issues with PSHCP and getting straight answers about IVF.  I read a good bit of this forum but may have missed a few things, one thing I didn't see that to me needs to happed is we need to press our Union, at the end of the day they negotiate with the government and the government sets what sunlife will and will not cover for us.  To me the fact that changes happened in late 2015, and we are still getting no word on what will change and when is not acceptable.

 

I don't need to tell people here the stress that being caught up in arguments over insurance can add to this issue already, but I personally have not felt like there is much of a commitment to get it fixed and maybe our unions don't know how many members are struggling?

 

Anyways good luck to all, and if I hear of any movement I'll let everyone know



#437 upsidedownv

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Posted 01 February 2018 - 03:29 PM

Hello - I've been trying to get information on the coverage review from Sunlife - with no luck at all.

 

I was wondering, has anyone heard any updates? Or had any luck contacting the Public Health Administration office? I've been thinking about bringing it up to my union, MP and pretty much anyone and everyone who might be able to get things moving. It will probably be too late to provide any financial assistance to my family, but I really think this has gone on for way too long. 



#438 Hopeful32

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Posted 06 February 2018 - 04:56 AM

Infertility is a medical condition and not a choice. IVF, surrogacy, etc costs are hugely burdensome.

Perhaps interested parties can approach the union instead of just the insurance company?

Saw this notice recently:

"The Bargaining Agents of the National Joint Council will soon be approaching your employer to negotiate improvements to the Public Service Health Care Plan."
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#439 deformedswimmers

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Posted 08 February 2018 - 03:57 PM

I got to be honest Ive contacted the union 4-5 times and received very little help beyond saying were in negotiations I was not at all left with the feeling they took this issue seriously.

I actually found a case where the CAF was forced to concede in court and pay for IVF and I forwarded to them and didnt receive much back from them.

Im in the process of contacting them again but I have very little hope to be honest.

#440 Hopeful32

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Posted 09 February 2018 - 03:28 AM

Curious if you're able to share that court case link?

Your union reps rebuffed you even after being informed of the court case!?

#441 deformedswimmers

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Posted 09 February 2018 - 11:32 AM

I can definitely share the court case, I want to make it clear, the Union didnt rebuff me, Ive been frustrated as have many of us have. I feel that while the on and off contact Ive had with the union for close to 2 years now has been positive in tone, I dont feel the understand the impact or timeliness issues many of us face. I guess I feel like better IVF coverage is just another possible bargaining chip rather than something they have truly shown me they care about.. my super simple understanding of our coverage is that if something is covered in the public system in a province then the rest of us should get it through our coverage in other provinces. I know that is over simplified but basically I dont feel I or any of us should have to wait for the next round of bargaining for this to be dealt with. I also feel like they should be collecting info and lodging formal appeals for every single denied case for 2 reasons; firstly to keep our rights to reimbursement open of this benefit is allowed in the future and secondly to have actual data on the numbers of staff affected. I personally know of 3 others here that have done IVF maybe 4 but I dont know if they are pushing the union to fight for them, its not my place to investigate. But the union could easily send something out about changing times and needs and medical issues and MANY people may self identify.

I want to be clear I dont know that they are not fighting for me, but they have left me feeling like its not a super important issue to them.

Anyways here is the link hope it still works. http://www.forces.gc...e-coverage.page

#442 deformedswimmers

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Posted 09 February 2018 - 11:37 AM

Sorry I made a mistake there was a case, but this is the CAFs ACTUAL COVERAGE. If you go down to infertility they cover issues WELL beyond ours such as male factor.

To me this is even a bigger deal b/c that means their plan has actually been changed and ours has not

#443 outdoorsliving

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Posted 13 August 2018 - 07:28 PM

Not sure if people are still following this or not.  I received a letter in the mail today with an update on IVF coverage and the PSHCP with Sunlife.  (I wrote to my union, Treasury Board and to Sun Life fighting for IVF coverage over a year and a half ago).

 

"We wish to inform you that the PSHCP Partners Committee (Committee) has reached a decision with regards to the eligibility of IVF under the Plan.  After careful consideration, the Committee has determined that IVF procedures and associated costs are not eligible for coverage under the PSHCP. The Committee based its decision on numerous factors, including Plan sustainability, cost, and comparability with other employer-sponsored plans.

 

....

 

Currently Ontario is the only Province that insures IVF, provided specific criteria are met. As such, IVF related physician expenses incurred by members residing in territories or provinces other than Ontario are eligible for reimbursement under the PSHCP, so as long as the patient's condition meets the criteria established by the Ontario Health Insurance Plan.

 

While Sun Life is aware that the Province of Ontario announced changes to its IVF Coverage in 2015, we have received direction to maintain the current adjudication process in OHIP's previous eligibility criterion.  This criterion allowed for up to three cycles of IVF treatment payable, if the patient suffered from a complete bilateral blockage of the Fallopian tubes.  In order to complete our review, Sun Life requires confirmation from your physician that XXX suffers from a total bilateral blockage of the Fallopian tubes."

 

Then it goes onto saying the drugs will qualify under the plan.  So basically if you don't live in Ontario the only way you will be covered by having total blocked tubes and they don't care it was changed. th_agrr.gif



#444 Hopeful32

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Posted 14 August 2018 - 05:16 PM

This is unfair for people in Ontario too.

If you meet Ontario's old criteria and live in Ontario, the health insurance will not cover 3 IVF cycles.

However, it looks like if you meet Ontario's old criteria, and live outside Ontario, the health insurance plan will cover 3 IVF cycles.

#445 deformedswimmers

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Posted 19 January 2019 - 07:09 PM

Ive received nothing for our claim, and regularly dont hear back from my union when I try to touch base.