Thanks to the Pharmaceutical Benefits Scheme (PBS), Australians don’t usually pay full cost for prescription medications purchased from pharmacies. Instead, we only pay part of the cost of the medicine, with the remainder subsidised by the government. But not all prescription medications are subsidised by the Government under the PBS – that's where private health insurance can help.
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.
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.
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.
| Response | WA | VIC | SA | QLD | NSW |
|---|---|---|---|---|---|
| No | 48.11% | 45.93% | 58.67% | 46.19% | 40.58% |
| Yes | 37.74% | 37.04% | 28% | 35.03% | 42.17% |
| Somewhat | 14.15% | 17.04% | 13.33% | 18.78% | 17.25% |
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:
Extras that includes pharmaceutical cover doesn't usually have any waiting periods. However, hospital cover generally has a 2-month waiting period, or 12 months for pre-existing conditions.
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: your name, the script number and the name of the drug prescribed.
There are some situations where you cannot claim the cost of prescription medication on your private health insurance extras cover, including:
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 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.
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