Health insurance for non-PBS pharmaceuticals
Get cover for non-PBS pharmaceuticals with high-level extras insurance.
Key takeaways
- Medications on the PBS are subsidised by Medicare, but you'll have to pay a co-payment.
- Non-PBS medications can be partly covered by a private extras policy.
- Private cover will still attract a co-payment, and there'll be per-item and yearly limits.
What is the PBS?
The Pharmaceutical Benefits Scheme, or PBS, is a list of subsidised medicines offered to Australians. It's super valuable, because some medicine costs an ungodly amount of money. However, the PBS doesn't cover every drug, so you may want to consider health insurance that covers non-PBS items.
PBS co-payments
PBS drugs aren't fully subsidised, there is a co-pay, an out-of-pocket cost you'll need to pay for each drug. It ranges from a maximum of $7.70 for concession card holders, up to a maximum of $25 for everyone else (the general co-payment dropped from $31.60 on 1 January 2026 and will be indexed each year from 2027). The PBS Safety Net will kick in if you spend a lot in a single year. That means you'll only ever pay a maximum of $277.20 for concession card holders and $1,748.20 for general patients on PBS drugs each year.
How are medications covered in Australia?
Medications can be covered by either Medicare, Australia's public healthcare system, or private health insurance. The details vary though.
- Public health system: Medicare will cover a lot of the cost of drugs on listed the PBS, with a small out-of-pocket cost. Medicare will not reduce the cost of drugs that aren't on the PBS.
- Private health system. Private cover won't do anything for medicines on the PBS, but can help with the cost of non-PBS pharmaceuticals. The health funds will also require a co-pay amount, normally the same amount as the current Medicare PBS co-payment.
What costs will my health fund cover?
Cover for non-PBS medications is included on some medium or high level extras policies from Australian health funds. However, cover is only included if the non-PBS medication:
- Costs more than the current PBS co-payment amount.
- Is dispensed by a registered pharmacist in a private practice.
- Is prescribed to you by a GP, and is only available by prescription.
- Is listed on the Australian Register of Therapeutic Goods.
The exact level of cover provided depends on the health fund and the policy you choose. Most have a per-item claim limit, eg $50, as well as a yearly limit, eg $300. Those limits change a lot between policies.
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Hi, question. Do you have a policy with extras that can help cover non pbs / wegovy prescriptions?
Hi Dani, As the guide notes, you’ll need an extras policy to cover this, and most will have limits on how much they’ll pay per year.