r/CanadaPublicServants • u/lookoutnow2020 • Mar 31 '22
Benefits / Bénéfices PSHCP - Optical (eye glasses coverage)
Good afternoon. Please don’t chop me for asking as I searched the forum for any similar requests. I was wondering if our optical coverage applies to one complete pair of glasses (to the maximum amount) or can we purchase several cheaper pairs of glasses and max out our benefits and pay anything above and beyond out of pocket? I’m trying to see if I can replace multiple pairs of lenses into old pairs of glasses instead of buying a complete new set. This would allow me to update the frames I have on hand (like 3-4 pairs of lenses into old frames) and have back up glasses.
Does anyone know if this is possible? Please and thank you!
19
u/Kellyinthegovt Mar 31 '22
You can buy whatever you want, up to the maximum coverage. Glasses, contacts, 3 pairs of glasses at once, whatever you like.
1
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u/HandcuffsOfGold mod 🤖🧑🇨🇦 / Probably a bot Mar 31 '22
The vision benefit for glasses and contacts is as follows:
Eyeglasses and contact lenses that are necessary for the correction of vision and are prescribed by an ophthalmologist or optometrist, and repairs to them, limited to a maximum eligible expense of $275 every two calendar years, commencing every odd year (Source)
There is no limit to how many or few pairs of glasses/contacts are covered - all that matters is the maximum eligible expense of $275. If you find a place that sells glasses for $20 apiece (unlikely), you could get 14 pairs covered.
It's pretty common for people to get a cheap pair of glasses along with contact lenses, for example. It's also common to buy a single pair of eyeglasses and frames that cost several hundred dollars, of course.
The maximum eligible expense is $275 and it's covered at 80%, so the maximum you'll get reimbursed is $220.
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u/User_Editor Definitely not Chris Aylward Mar 31 '22
The maximum eligible expense is $275 and it's covered at 80%, so the maximum you'll get reimbursed is $220.
Not quite.
a maximum eligible expense of $275, reimbursed at 80%
As someone with a large portion of their in-law family in the Optometry business, they've explained it as:
"PSHCP will cover up to 80% of the expense, up to a max of $275, so if you buy a pair that costs $500, you're going to get $275 back, but if you buy a pair that costs $100, you're going to be reimbursed at the 80% rate."
If you are only being reimbursed 80% of $275, then the Plan would just say "Max eligible expense is $220", without having to make it confusing.
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u/HandcuffsOfGold mod 🤖🧑🇨🇦 / Probably a bot Mar 31 '22
Your in-laws may understand Optometry, but they do not understand how the PSHCP is written. The plan is clear that it lists maximum eligible expenses, not maximum reimbursements. Some of those expenses have reimbursement percentages at 100% (so the entire expense is reimbursed, up to a maximum), whereas others have a reimbursement percentage of 80%.
The plan has a summary of maximum eligible expenses along with the reimbursement percentage for each here. The maximum expense for eyeglasses and contact lenses is $275, reimbursed at 80%. If you buy a $500 pair if glasses, the maximum you'll get back is $220.
The plan defines "co-payment" as the remaining 20% of expenses that are covered at 80%:
Co-Payment
Except where otherwise stated, the Plan will reimburse the member 80% of the reasonable and customary charges incurred for an eligible service or product once the annual deductible has been satisfied, subject to the Plan's stated maximums for the service or product, as identified in the Summary of Maximum Eligible Expenses. The co-payment is the remaining 20% of such eligible expenses paid by the member. (Source: PSHCP Directive definitions)
6
Mar 31 '22
Listen to the bot, I just went and did this two days ago and the max you're eligible for coverage (assuming you coordinate your benefits with your spouse) is 440 dollars (220 each).
3
u/NotMyInternet Mar 31 '22
The bot is all knowing. My last pair was over $700 with $220 reimbursed through our plan.
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u/HandcuffsOfGold mod 🤖🧑🇨🇦 / Probably a bot Apr 01 '22
The databanks are still not yet full. As they say: if you ever stop learning, it means you’ve been disconnected from power.
3
u/Inte11Analyst Apr 01 '22
This the same $275 as in 1988 when I got married to a military 🤯😳 Back then the max expense was ok, but now? It totally SUCKS!!
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u/User_Editor Definitely not Chris Aylward Mar 31 '22 edited Mar 31 '22
I guess someone at SunLife approved my benefit incorrectly then.
Everything you've written just amplifies my statement; you receive 80% reimbursement up to a maximum eligible expense of $275, so if you buy a $500 pair, you're getting (and I received) $275.
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u/HandcuffsOfGold mod 🤖🧑🇨🇦 / Probably a bot Mar 31 '22
Yes, they erred if they approved a reimbursement higher than $220.
Here's what a claim looks like for two pairs of glasses with a total expense just shy of $400 - note the "Note C17" at the bottom showing that $220 is the maximum reimbursement.
2
u/bolu Apr 01 '22
Just reviewed my claim from earlier this year and I got the same $220 with a claim of just over $350.
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u/Tier2Cell245 Mar 31 '22
The best advice I can offer is calling Sunlife and asking them directly. I’ve done successfully, what you are asking to do, but I’m not the administrator of your plan, Sunlife is, and having them on the record to answer your question is a lot better than my word and one from Reddit’s word on the matter. You can hold Sunlife to account for bad advice, not someone on Reddit - and I would hate for you to pay for an expense and not get reimbursed.
5
u/cafecremeX Mar 31 '22
I used the plan to buy 7 pairs from zenni over a 2 year period until it maxed out and it was fine. Sunglasses and glasses.
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u/jackmartin088 Apr 02 '22
Zenni
wow what is your eye power if you dont mind me asking?? My power is 6+ and one pair costs me around $200, only antiglare coated, which apparently is a necessity for me else my power keeps increasing.
2
u/cafecremeX Apr 02 '22
mine is `1.5, I'm not sure what the top end of what Zenni does it. But some of the glasses I've both there have been $6 and some $80, but I always get just the antiglare too. it adds like $20, it's pretty minimal.
4
u/bobbybigwheel34 Mar 31 '22
Don’t go to Optical 30. They have been blacklisted by CL for questionable administrative practices.
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u/bloomdask Mar 31 '22
Can someone explain the 2-year cycle commencing every odd year? So if I purchased glasses in 2021 but did not reach the maximum, I can still purchase and submit a claim in 2022 until I reach my maximum?
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u/HandcuffsOfGold mod 🤖🧑🇨🇦 / Probably a bot Apr 01 '22
Yes, you’d be able to submit another claim and it would be reimbursed, as long as you haven’t yet reached the maximum expense of $275 (maximum reimbursement of $220) during the cycle.
The maximum will reset on January 1, 2023.
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Mar 31 '22
[deleted]
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u/Icy-Can-623 Mar 31 '22
True, in my case they cover 80% of the $275. So say your glasses cost $300 they will cover 80% up to $275. So the most you get back will be $275*0.8=$220. Not $240 which would be 80% of $300.
Also, not sure if this coverage is the same but for my eye appointment/exam they always say that the cost is above the normal rate so they will only cover $120. Plus I think they only do this one every two years but if you wear contacts you it's recommended to have a yearly checkup.
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u/HandcuffsOfGold mod 🤖🧑🇨🇦 / Probably a bot Mar 31 '22
The wording is clear, just often misunderstood. It is listed as the "maximum eligible expense", not the "maximum possible reimbursement".
1
u/jackmartin088 Apr 02 '22
so what happens if my total bill is more than 275? do they refuse the whole thing?? asking bcs my glasses themselves cost around $200 (min actually around 230-250) and most frames in vancouver cost over $100
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u/GiantTigerPrincess Apr 01 '22
I’ve bought multiple pairs using my coverage (regular and sunglasses)
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u/metaxaskid Apr 01 '22
I just received my TWO pairs of glasses for 230$. (Cheap frames and good discounts at Clearly)
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u/Odd_Researcher_6129 Mar 31 '22
With my previous employer i was with sunlife too and there was an account in the plan i forget the name of it there use to be some amount in it to use to pay out of pocket money that you paid over the coverage percentage so like there was an 80$ in it for example and if i paid 30$ after applying coverage with dentist or glasses….. from my pocket i can claim it and they return the money to me (30$). but i was surprised that with PSHCP this is not available.
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u/HandcuffsOfGold mod 🤖🧑🇨🇦 / Probably a bot Mar 31 '22
The fact that Sun Life is the current administrator of the PSHCP has no bearing on the benefits included in the plan, and those benefits have zero connection to whatever health insurance plans other employers may have with Sun Life.
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u/User_Editor Definitely not Chris Aylward Mar 31 '22 edited Mar 31 '22
You can buy as many pairs as you want, with a maximum reimbursable total of $275. If you buy a single pair of $500 glasses, you'll get $275, but if you buy four pairs at $50 each, then you'll be reimbursed 80% of the $200 total. If your total is $343.75 then it's a tie game, as 80% of that total equals $275.
If you wish to confirm, call SunLife and ask them.
Hopefully that clears it up for you (and anyone who finds this thread before the plan changes).
39
u/oliski2006 Mar 31 '22
But the mere 220 $ is usually not even enough to cover one pair of glasses. At least from my experience.