Administrative Fees and Ineligible Expenses
October 30, 2019
It is a common misconception that all prescribed services and products are eligible for reimbursement under the PSHCP. Over-the-counter drugs like aspirin that can be obtained without a prescription, for example, cannot be claimed under the PSHCP even when they are prescribed by a physician. However, thousands of claims for over-the-counter drugs are submitted and declined every year which translates into significant costs to the PSHCP. The Plan absorbs the administrative cost of each transaction, whether the processed claim is eligible or not. Listed below are all of the exclusions under the PSHCP’s Drug Benefit.
- Expenses for drugs, which in the Administrator’s opinion, are experimental,
- publicly advertised items or products, which in the Administrator’s opinion, are household remedies,
- expenses for vitamins, minerals, and protein supplements other than expenses that would qualify for reimbursement under Eligible expenses,
- expenses for therapeutic nutrients other than those that would qualify for reimbursement under Eligible expenses,
- expenses for diets and dietary supplements, infant foods, and sugar or salt substitutes other than expenses that would qualify for reimbursement under Eligible expenses,
- expenses for lozenges, mouth washes, non-medicated shampoos, contact lens care products, and skin cleansers, protectives or emollients,
- expenses for drugs used for cosmetic purposes,
- expenses for drugs used for a condition or conditions not recommended by the manufacturer of the drugs (off-label use),
- expenses incurred under any of the conditions listed under General Exclusions and Limitations, and;
- expenses payable under a provincial/territorial drug plan whether or not the participant is a member of the plan.
Since pharmaceutical products are not all covered under the Plan, you may wish to contact the PSHCP Call Centre to confirm their eligibility prior to your purchase. The Call Centre may be reached at 1-888-757-7427 (toll-free from anywhere in North America) or at 613-247-5100 (from the National Capital Region). Alternatively, consider using Sun Life’s digital services available on the Plan Member Services Website or the my Sun Life Mobile app. The Drug Look-Up tool, for example, allows you to search a specific drug by name or by drug identification number (DIN) and obtain detailed information about a drug, its indications and clinical use. It also allows you to find information about a drug’s average cost per prescription and the cost of any alternatives suggested, potential generic or therapeutic alternatives and cost-saving solutions, confirm whether or not a drug is covered under the PSHCP, and review claims summaries for recent prescriptions.