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Health insurance for non-PBS pharmaceuticals

Does health insurance cover prescriptions? What you need to know about prescription medication insurance.

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The Pharmaceutical Benefits Scheme (PBS) is a list of prescribed medicines that are subsidised by the Australian Federal Government. The PBS is administered by Medicare Australia and managed by the Department of Health.

However, there are plenty of prescribed medicines that are not featured on this list; these are known as non-PBS medications and must be paid for out of your own pocket. If you take out private health insurance that covers non-PBS medications, you can receive financial support to help you purchase the medication you need.

Compare your cover options for extras policies

What costs will my health fund cover?

Cover for non-PBS medications is included on some high-level extras cover policies from Australian health funds. However, cover is only included if the non-PBS medication:

  • Costs more than $38.30.
  • Is dispensed by a registered pharmacist in a private practice.
  • Is only available when prescribed and 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. Your health fund will most likely impose a limit on the amount you can claim per item, for example $50.

It might also limit the maximum amount of pharmaceutical benefits you can claim each year. This annual limit may increase the longer you are a member of the fund.

How do Australian health funds cover non-PBS items?

Health fundWhat level of cover do these funds offer for non-PBS medication?Find out more
HIF LogoHIF allows members to claim a maximum benefit of $80 per script above the PBS co-payment, up to a maximum annual limit of $200 in the first three years of cover, or $400 after three years.More info
Picture not describedOnce you’ve made the co-payment for your non-PBS medication, pays back a percentage of the remaining cost based on the extras cover you select. High Extras has an annual pharmacy cover limit of $200.More info
CBHS health insurance

Restricted fund

  • CBHS health fund restricts its membership to current and former staff (including their families) of Commonwealth Bank Group and their subsidiaries which include Aussie, Bankwest, Colonial First State and more.

Top, Intermediate and Basic Extras policies offered by CBHS all include cover for non-PBS medication, although with varying overall limits, which are $1,000 for Top Extras, $300 for Intermediate Extras and $200 for Essential Extras.

More info
ahm health fundPharmacy cover as part of the AHM Super Extras policy includes cover for general items (excluding PBS scripts, over-the-counter medicines, vitamins and herbal medicines), hormonal implants, contraceptives for medical reasons and preventive/travel vaccines. Up to $60 above the general patient PBS amount is covered for each item, up to a maximum annual limit of $650.More info
australian unity logoCover for non-PBS pharmaceuticals varies depending on the Australian Unity extras policy you select. For example, the Comprehensive Extras policy allows you to claim up to $30 per script up to a maximum annual limit of $500 per person, while Super Extras covers up to $55 per script up to $300 per person per year and $600 per family.More info
GMHBA health fundSilver Extras cover from GMHBA covers up to $24 per script up to an annual limit of $250 per person, or $450 per family.More info
HCF logoHCF Platinum Extras Cover provides cover for up to $50 per script after you’ve made the PBS equivalent co-payment, up to a maximum annual limit of $250 per policy.More info
Top Extras policy from nib covers up to $500 of non-PBS pharmaceuticals each year.More info
transport health logoTransport Health Top Extras covers pharmacy costs up to a maximum annual limit of $400 per person, or $800 per policy.More info

How are medications covered by the public and private health systems?

  • Public health system. In Australia this is known as Medicare, and it is responsible for administering the Pharmaceutical Benefits Scheme (PBS) which contains a list of all medicines offered to Australians at a subsidised price. However, this list does not include all drugs, which is why you may want to consider taking out health insurance to cover non-PBS items.
  • Private health system. If you want cover for the cost of non-PBS pharmaceuticals, you will need to take out a private health insurance extras policy that includes cover for pharmacy costs. Even with such a policy in place, you will need to cover a portion of the cost of the medication – currently $38.30 – before your private health insurance will kick in and cover the remaining purchase price up to a set limit per script.

The example below outlines how the cost of non-PBS medications are shared by you and your health fund:

How do I claim non-PBS pharmaceuticals on my health insurance?

If you wish to claim a benefit for pharmaceuticals, you can usually do so using one of the normal extras claim options offered by your health fund. You will first have to pay a portion of the cost of the medication before claiming the remaining purchase price back using one of the following methods:

  • On the spot by swiping your health fund membership card
  • Online through your health fund’s member services centre
  • Via your fund’s mobile claims app
  • Over the phone with your health fund
  • Via email, post or fax
  • By visiting a health fund branch

You’ll also need to include an official pharmacy receipt with your claim. This receipt must show your name, the script number and the name of the drug you’ve purchased. Most pharmacies will include the designation (Private or “Priv”) on the receipt, which indicates that the script is for a non-PBS pharmaceutical and is covered by private health insurance.

What is prescription medication?

Prescription medications are active medicinal products that perform a therapeutic, preventative or functional role. These medications can divided into two categories:

  • Internal. Medications taken in tablet, pills or liquid form
  • External. Items such as salves and lotions

In order to be able to purchase one of these medications, they must usually be prescribed to you by a doctor. However, in some cases you can also receive a written prescription from a dentist, optometrist or a midwife.

Doctors and specialists prescribe these medications for you in order to help your body fight off illness or disease, or to better manage a pre-existing condition. Your doctor will give you a written prescription that contains a range of information about the medicine you need including its name, the form in which you will take it, the quantity to be dispensed and the dose you will need to take.

What can I expect from my pharmacist?

Once you are given a script by your doctor or specialist, you’ll need to head to your nearest chemist or pharmacy to pick up your medication. Head to the counter with the big “Prescriptions” sign and hand your script to the pharmacist.

The pharmacist will dispense the medication you need – this is also referred to as filling your prescription – and provide you with instructions on the correct dosage and how to safely administer the medication.

You can also visit your local pharmacist for advice on minor health concerns and ailments, to help you access important health services such as immunisations and to provide health screenings to help you assess your overall well-being.

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