If you have pharmacy on your cover, you may be able to claim benefits towards pharmacy items that aren’t listed on the Pharmaceutical Benefits Scheme (PBS), as long as the items are prescribed by a medical practitioner and are prescription only.
Do I have pharmacy on my cover?
Check out your product guide to see if pharmacy is included on your cover.
What is the Pharmaceutical Benefits Scheme (PBS)?
The government helps to make some prescription medications more affordable by listing them on the Pharmaceutical Benefits Scheme (PBS) and paying for part of them.
The PBS sets the remaining amount that a patient pays towards the cost of subsidised drugs. This is called a co-payment. Private health insurers can’t pay any benefits towards a co-payment or any medications listed as part of the PBS.
Pharmacy items you can claim on
If your extras cover includes pharmacy, we’ll pay a set benefit amount per eligible item towards non-PBS pharmacy items that are prescribed by a medical practitioner and are:
- Essential to treat a particular illness injury or condition.
- Prescription only, including oral contraceptives and cosmetic pharmaceuticals for medical conditions, travel and other vaccinations (unless dispensed at the medical practitioner’s clinic), and hormonal implants.
Oral contraceptives and cosmetic pharmaceuticals for medical conditions require a referral letter from a medical practitioner to claim. The letter must be dated prior to your purchase, and is valid for 12 months, unless otherwise specified.
To claim on compounded medications, select the Claim Form on the upload documents page and attach both your Claim Form and your receipts. You can also send your forms by post to Locked Bag 4, Wetherill Park NSW 2164.
Before we pay any benefits, you must cover the general patient PBS co-payment. This means that we will pay benefits towards any cost above the general patient PBS co-payment up to the maximum benefit amount on your product. Please note, the general PBS co-payment amount changes each year on 1 January.
If pharmacy is included on your cover, an annual limit applies. You may also be subject to waiting periods. Check your product guide for more details on this and your eligible benefit amounts.
Pharmacy items you can’t claim on
We won’t pay any benefits toward:
- Pharmacy items that are already subsidised by the PBS
- Non-PBS pharmacy items that cost less than the co-payment amount
- Oral contraceptives (unless they’re prescribed for purposes other than contraception)
- Pharmacy items prescribed for cosmetic purposes
- Any pharmacy items without a prescription
- Herbal medicines
- Any over the counter items
If in doubt, chat to your pharmacist and doctor about whether your pharmacy item is eligible for benefits. If it meets the criteria above and is not appearing in the search you can submit your claim for manual assessment. Simply select the Claim Form option on the upload documents page and attach both your Claim Form and your receipts. You can also send your forms by post to Locked Bag 4, Wetherill Park NSW 2164.
Message us if you get stuck or have any questions.