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Participating Health Funds

Non-PBS pharmaceuticals and your health insurance

pharmaceuticals borderWhat are non-PBS pharmaceuticals?

Non-PBS pharmaceuticals include any drug that is not listed on the Pharmaceutical Benefits Scheme (PBS).

The Pharmaceuticals Benefits Scheme (PBS) subsidises the cost of various drugs, resulting in the consumer paying a reduced price for certain drugs. On average, the PBS reduces the cost of drugs by about 80%, meaning the cost of a non-PBS pharmaceutical can be every expensive in comparison.

Having an insurance policy that will rebate the cost of non-PBS pharmaceuticals will help reduce the amount you will have to pay for these drugs. Health funds cover non-PBS pharmaceuticals under extras cover.

Who needs non-PBS pharmaceuticals?

Many drugs that have been left off the PBS have been considered by the government to be non-essential. However some of these drugs can be necessary for the well-being of people at different times in their lives.

For example, newer brands of the contraceptive pill, such as Diane-35 and Yasmin, are not on the PBS list, as are drugs like Nasonex, which is used to treat chronic hay fever and nasal infection. Many new and experimental drugs may also not be included on the PBS.

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

Making your claim

It is important to check that your health fund will pay benefits for your non-PBS pharmaceuticals. Some health funds have their own approved list of non-PBS pharmaceuticals to which they will pay a benefit towards, and in some cases, other conditions may exist which determine whether your health fund will pay a benefit towards the drug or not (eg. your doctor may need to provide details as to why you need the drug).

Waiting periods

Like other extras features, you must be covered for non-PBS pharmaceuticals under your health insurance plan if you wish to claim benefits for this feature.

If you are required to serve waiting periods, they must be completed before your claim is valid. Usually, non-PBS pharmaceuticals benefits only have a 2 month wait, which may be waived in the form of a special offer from the health fund, or if you switch from another health cover that also included non-PBS pharmaceutical benefits.

Claim eligibility

The amount that your health fund will pay depends on the level of cover you have with them. Health funds will pay a capped benefit for each prescription (either a dollar amount or percentage of the cost), and these are combined together to create the maximum claimable amount in any 12 month period. That amount may be higher on a more expensive health cover plan, and lower on a more basic plan.

Please note: This information is provided as a general guide only, and should not be used as a substitute for advice provided by a medical professional or your health fund. We highly recommend you consult a doctor if you are concerned about your health, and speak with your health fund for specific health insurance-related queries.

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