Does health insurance cover prescription medication?

Can I claim money back on prescription medication?

Yes, mid-level extras cover can help pay for the cost of prescription medications. Extras policies typically only provide cover for prescription drugs that aren't subsidised under the PBS – which otherwise, without insurance, you'd have to pay the full price for.

Most policies let you claim between $200 and $500 per year for prescription medication. Some health funds also impose a sub-limit you can claim on each individual script. This could be a flat figure, for example $30 per script, or a maximum percentage of the cost of the script.

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How does health insurance cover prescription drugs?

Hospital cover

Inpatient pharmaceuticals are included in hospital cover. Policies can help pay for medications provided to you while you are being treated as an inpatient in hospital.

Extras cover

Mid-range extras cover can be used to cover the cost of non-PBS pharmacy items that are prescription-only and prescribed by a medical practitioner like your GP. This can include contraceptives for medical conditions, travel vaccinations, medically necessary hormonal implants and more.

When can I claim money back?

In order to make a prescription medication claim on your extras policy, your doctor will need to prescribe medication that is not subsidised under the PBS. The medication must also:

• Cost more than $25.00
• Be a category S4 or S8 item (prescription-only medicines or controlled drugs)
• Be prescribed by a registered medical practitioner, dentist or nurse and only be available on prescription
• Be dispensed by a registered pharmacist
• Be approved by the Therapeutic Goods Administration (TGA) for sale within Australia

Extras that include pharmaceutical cover normally sit under the general extras waiting period on your policy, so you may need to wait before you can claim - check with your fund. However, hospital cover generally has a 2-month waiting period, or 12 months for pre-existing conditions.

How do I make a pharmacy claim?

The way you claim for the cost of prescription medication may vary depending on the extras claim options supported by your health fund. These include:

• On-the-spot claiming. This is done by swiping your health fund membership card.
• Online claiming. You can lodge a claim via the online members section of your health fund’s website.
• Mobile claiming. Many health funds offer quick and convenient claims apps.
• By post. You can download a claims form and return the completed form to your fund.
• In-person. You can also lodge claims by visiting one of your health fund’s retail centres.

Your claim must be accompanied by an official pharmacy receipt which includes: your name, the script number and the name of the drug prescribed.

When can’t I make a pharmacy claim?

There are some situations where you cannot claim the cost of prescription medication on your private health insurance extras cover, including:

• If you have received the medications through the PBS or some other Government funding scheme.
• If the medication has not been approved for use by the Therapeutic Goods Administration (TGA).
• If the medication can be purchased without a prescription.
• If the medication is only dispensed via prescription to hospital in-patients (the cost of these drugs can be covered by hospital cover).
• If the drug is used as a contraceptive. If it has been prescribed to treat a diagnosed medical condition rather than for contraception, check with your fund before you assume it is excluded.
• If the drug is listed on your health fund’s exclusions list.
• If the medication is a compounded or experimental drug.
• If the medication is a natural remedy of any kind.
• If you have not served the waiting period imposed by your health fund for prescription medication.

What’s the difference between claiming on private health and on Medicare?

Medicare

Public health services in Australia are provided by Medicare. Medicare only covers medication listed on the PBS. You'll need your Medicare card to access subsidised medication. The subsidy is usually included when you pay for it at the pharmacy. If your doctor prescribes medication that isn't listed on the PBS, you'll need to pay the full cost yourself.

Private health insurance

Private health insurance is essentially designed to cover the services that Medicare doesn't help out with. This can include medication prescribed by your doctor that isn't listed on the PBS. You might need to make a co-payment towards the total cost of medication. Some providers will allow you to claim your benefit on the spot at the pharmacy; others will reimburse you once you've submitted the claim online.

FAQs about prescription medicine

• What level of extras cover do I need to claim prescription medication?

  Generally, you will need a mid-level extras policy to claim for non-PBS prescription medication. Basic or starter extras policies often do not include pharmaceutical cover or have very low annual limits and sub-limits. Always check the policy's PDS to confirm what non-PBS pharmaceuticals are covered and what limits apply.

• Does health insurance cover prescription medication for pre-existing conditions?

  Yes, extras cover can help with prescription medication for pre-existing conditions. Unlike hospital cover which often has a 12-month waiting period for pre-existing conditions, pharmaceutical benefits under extras cover usually do not have specific waiting periods for pre-existing conditions. However, the general waiting periods for extras cover still apply.

• Are weight management medications covered by private health insurance?

  Some private health insurance policies, particularly higher-level extras plans, may offer benefits for weight management medications that are not listed on the Pharmaceutical Benefits Scheme. This cover is not standard across all policies. You will need to check with your health fund or review the PDS to see if specific weight management drugs are included and what conditions or limits apply.

• Can I claim for mental health medications with private health insurance?

  Yes, you may be able to claim for mental health medications through private health insurance if they are prescription-only items not subsidised by the PBS. These would typically be covered under the non-PBS pharmaceutical component of an extras policy. Always confirm with your health fund that the specific medication is covered and understand any annual limits or sub-limits on claims.

• Does private health insurance cover travel vaccinations?

  Yes, many extras policies include cover for travel vaccinations that are prescribed by a doctor and are not covered by the PBS. This can be a valuable benefit if you plan to travel internationally and require specific immunisations for your destination. Check your policy's pharmaceutical or vaccination benefits to see what is included.

• Are fertility medications covered by private health insurance?

  Some private health insurance extras policies may offer benefits towards the cost of fertility medications that are not listed on the Pharmaceutical Benefits Scheme. This type of cover is usually found in more comprehensive extras policies due to the high cost of these medications. In this case, it's best to confirm with your health fund if your specific fertility medications are covered and what annual limits or sub-limits apply.

• What is the minimum cost of a prescription before I can claim on health insurance?

  To claim on your extras policy for prescription medication, the cost of the medication must be more than the current Pharmaceutical Benefits Scheme patient contribution amount. Currently, this threshold is $25.00. If your non-PBS prescription costs less than this, you typically cannot make a claim.

To make sure you get accurate and helpful information, this guide has been edited by Tim Bennett as part of our fact-checking process.

Written by

Gary Ross Hunter

Journalist

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Gary Ross Hunter has over 6 years of expertise writing about insurance, including life, health, home, and car insurance. Having reviewed hundreds of product disclosure statements and published over 800 articles, he loves simplifying complex insurance topics for everyday readers. Gary has contributed to major outlets like Yahoo Finance, The Sydney Morning Herald, and news.com.au, and holds a Bachelor of Arts (Honours) in English Literature from the University of Glasgow, along with a Tier 2 General Advice certification, ensuring his work adheres to ASIC’s RG146 standards. See full bio

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