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Under Australia’s Pharmaceutical Benefits Scheme (PBS), Australians generally don’t pay full cost for a wide range of prescription medications purchased from pharmacies. Instead, they only pay part of the cost of the medicine, with the remainder subsidised by the Australian Government. However, not all prescription medications are subsidised by the Government under the PBS. If you want cover that helps with the cost of these drugs, you’ll need to take out private health insurance.
If you purchase a high-level extras cover policy from an Australian private health fund, your policy will most likely include some cover for the cost of prescription medication. Extras policies typically only provide cover for prescription drugs that are not subsidised under the PBS. The level of cover provided varies depending on the extras policy you choose. In addition to annual limits on the amount you can claim for prescription medication, for example $500 per year, your health fund will 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.
Health insurance can provide cover for both in-hospital prescription drugs and medications you receive when out of hospital. As a result, claims for prescription drugs can technically be filed under either a hospital cover policy or extras cover, so the policy that provides the cover you need will vary depending on whether you are an inpatient or an outpatient.
However, this article largely deals with cover for out-of-hospital pharmaceuticals, which is provided by extras health insurance.
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:
You must also have served any waiting periods imposed by the health fund and your membership must be fully paid and up to date.
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:
Your claim must be accompanied by an official pharmacy receipt which includes:
There are some situations where you cannot claim the cost of prescription medication on your private health insurance extras cover, including:
Regardless of whether or not you have private health insurance, you will only have to cover part of the cost of prescription medications purchased from pharmacies – the rest is covered by the PBS. You will need to present your Medicare card in order to access subsidised medication under the PBS. However, if your doctor prescribes medication that is not listed on the PBS, you will need to pay the full cost as Medicare will not provide cover. However, you can take out a private health insurance extras cover policy to help cover the cost of non-PBS medications, but you will usually need to make a co-payment towards the total cost of medications. Contact your health fund for details of the non-PBS medications included in cover and any limits that apply to your policy.
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Is it then correct that no drug that can be used as a contraceptive is ever covered by health insurance, regardless pf the purpose of the drug, i.e. as a treatment for PCOS?
Hi Trishka,
Thank you for getting in touch with finder.
You can get extras cover for non-PBS items. For example, with ahm – as part of the AM Super Extras policy, pharmacy cover includes cover for hormonal implants, contraceptives for medical reasons and preventive/travel vaccines.
For more info on this and health funds to compare with, kindly check out this page.
I hope this helps.
Please feel free to reach out to us if you have any other enquiries.
Thank you and have a wonderful day!
Cheers,
Jeni
I’m on Saxenda for weight control and it cost about $400 a month. Is there a health insurance cover I can take out which would help with the cost in Australia? Thank you.
Hi Dee,
Thanks for your message and for visiting finder – the leading comparison website & general information service built to give you advice in your buying decision needs. How are you doing today?
The answer to your question is YES. You can take out a health insurance for weight management. Here is the page for your perusal.
As part of their commitment to providing broader health cover, many Australian private health funds can help cover costs for members who participate in a wide range of health and wellbeing programs. From gym memberships and personal training sessions to swimming lessons for kids, these programs are designed to help health fund members achieve improved overall health and wellbeing.
If you take out extras cover with many Australian private health funds, you’ll be able to access benefits for a large selection of health, wellbeing, diet and lifestyle programs. These programs are designed to help fund members manage their weight, control chronic diseases and generally live healthier lifestyles.
Hope this helps! Feel free to message us anytime should you have further questions.
Cheers,
Nikki