Claiming pharmacy under private health insurance
Did you know health insurance can help to cover the cost of expensive medication?
Depending on your health fund and level of cover, you may have access to benefits that can help to cover the cost of certain medication, which you would otherwise be completely out of pocket for.
Prescription medication can be categorised into two groups when referring to accessibility and cost: those that are listed on the Pharmaceutical Benefits Scheme (PBS) and those that are not (non-PBS).
Pharmaceutical Benefits Scheme (PBS) – government subsidised medication
The Australian Government subsidises prescription medication through the PBS to provide all Australians who are eligible for Medicare access to more affordable medication. The patient co-payment is up to $31.60* ($7.70 for concession card holders) for most medications that are included in this scheme.
As these medicines are subsidised by the government, they cannot receive any additional benefits though private health insurance. A complete list of the medicines listed on the PBS can be found online.
While this list is extensive, not all medication is subsidised through the PBS. This is where private health insurance can help to cover the cost.
Non-PBS items - where private health insurance benefits can apply
Private health insurance can help to cover the cost of prescription medication that is not listed on the PBS. As this medication is not subsidised, it is typically more expensive to purchase.
The eligibility criteria or conditions around what kinds of non-PBS medication can be claimed, waiting periods, annual limits and individual item benefits varies across each health fund. It is important to check with your health fund what is available to you. Benefits for non-PBS items are usually included under extras or otherwise known as general treatment cover.
Your health fund may also have requirements for the information they need to process your claim. Pharmacies can provide you with an Official Pharmacy Receipt, which includes information about the supply of your medication such as patient name and script number. It may be a requirement of your health fund to submit this official receipt as part of your claim.
Medication provided during or after a hospital admission
So far we have addressed how private health insurance can cover prescription medication when purchased in an outpatient or community setting, such as after seeing your GP or specialist in their consulting rooms. But what happens with your medication when its part of a hospital admission?
- Medication provided during a hospital stay: medication provided as an inpatient in hospital is generally covered by hospital cover, if directly related to the admission. This is a cost you won’t see as a patient, with hospital claims usually processed between your health fund and the hospital directly.
- Discharge medication: you may be prescribed discharge medication to be used after leaving hospital. As you are no longer an inpatient in hospital, this medication is not covered as part of your hospital admission or under your hospital cover. These medications will fall under the same criteria set by your health fund for outpatient prescription medication.
*This is the patient co-payment amount set by the PBS. This patient contribution amount is adjusted on 1 January each year in line with inflation.
IMPORTANT: Private health insurance products are issued by The Doctors’ Health Fund Pty Limited, ABN 68 001 417 527 (Doctors’ Health Fund), a member of the Avant Mutual Group. Cover is subject to the terms and conditions (including waiting periods, limitations and exclusions) of the individual policy, available at www.doctorshealthfund.com.au/our-cover. © Avant Mutual Group Ltd 2024