Prescription Medication and Health Insurance

Health insurance and prescription medication

Health insurance that covers prescription medication? Find out exactly what you can claim back.

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.

Can you claim money back on prescription medication?

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.

What type of cover will someone need to claim for prescription drugs?

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.

  • Inpatient pharmaceuticals are included in hospital cover. Hospital cover policies provide cover for medications provided while you are being treated as an inpatient in hospital.
  • Outpatient pharmaceuticals are included in extras cover. Extras cover from your health fund can be used to cover the cost of pharmaceuticals received out-of-hospital as an outpatient, and that are not listed on the PBS.

However, this article largely deals with cover for out-of-hospital pharmaceuticals, which is provided by extras health insurance.

In what circumstances can you claim?

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 $38.30
  • Be a category S4 or S8 items (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 for sale within Australia

You must also have served any waiting periods imposed by the health fund and your membership must be fully paid and up to date.

How do you go about making a 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
  • The name of the drug prescribed

When can’t you 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.
  • 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 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?

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.

Picture: Shutterstock

Tim Falk

A freelance writer with a passion for the written word, Tim loves helping Australians find the right home loans and savings accounts. When he's not chained to a computer, Tim can usually be found exploring the great outdoors.

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2 Responses

  1. Default Gravatar
    DeeMay 8, 2018

    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.

    • finder Customer Care
      NikkiMay 8, 2018Staff

      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

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