Most HCi members will be required to buy prescription medication from time to time.  Here’s what you need to know about pharmacy claims for certain prescription medicines through your HCi private health cover.

What is the PBS?

For many drugs, Australians only pay some of the actual cost because the rest is paid for by the PBS. The PBS is a government program that subsidises the costs of certain medicines to make them more affordable. The PBS generally requires you to make a ‘PBS co-payment’ towards the cost of each prescription medicine.

You can find out more about how the PBS works on their website.

Can I claim for PBS medications through HCi?

No. Government regulations prevent private health insurers from paying towards the cost of medications that you can receive through the PBS.

Because we can’t determine whether individual HCi members are eligible for the PBS subsidy, medications that are listed on the PBS are generally excluded from HCi cover, unless you can prove that you have not received PBS subsidies for your prescription medication.

Not every medication is listed on the PBS and some PBS listed medications may have additional eligibility conditions to qualify for PBS subsidies. If your doctor prescribes a drug that if not listed on the PBS, or you don’t meet the relevant PBS eligibility conditions, you’ll be required to pay for the full cost of the medication, which could be expensive. This is where HCi may be able to help cover the costs through a pharmacy claim.

So when can I make pharmacy claims for prescription medication?

If you have eligible HCi extras cover, you’ll have cover for HCi-approved pharmacy items and may be able to claim up to $100 per script* for some non-PBS listed medicines, after a PBS equivalent co-payment.

For all pharmacy claims, you will need to provide HCi with an official pharmacy receipt that proves the PBS didn’t cover your medication (you may need to request this specifically from your pharmacist as it is different to a normal pharmacy tax invoice or receipt). Your official pharmacy receipt must show

• the name of the patient
• script number
• prescribing doctor information
• cost
• name of medication
• dispensed date.

What are HCi-approved pharmacy items?

To qualify as an HCi approved pharmacy item under eligible HCi extras cover, your prescription medicine must be prescribed by a medical practitioner in accordance with relevant Australian State or Territory legislation, and be supplied by a pharmacist or medical practitioner in private practice in Australia. Note that claims are not eligible for medicines obtained from overseas-operated websites (even if they have a .com.au address).

HCi will only consider a prescription medication for inclusion on our HCi-approved pharmacy list if it has been registered with the Therapeutic Goods Administration (TGA). The TGA is part of the Australian Government’s Department of Health and is responsible for regulating medicines, vaccines and other health related products in Australia.

There are some exclusions when it comes to what prescription medications HCi covers. Contraceptives, anabolic steroids or over-the-counter medications are a few examples of exclusions that may apply, depending on your extras cover type. Prescription medicines that are not classified as an S4 or S8 drug by the TGA are also excluded. HCi does not cover the cost of experimental drugs, treatments or procedures.

We may apply specific annual sub-limits and/or waiting periods to certain drugs. This includes sub-limits of $600 for medical Botox and $600 for some weight-loss, baldness and male erectile dysfunction prescriptions, and 12 months waiting period for medicinal cannabis.

In some instances, such as for medical Botox and medicinal cannabis prescriptions, we may also require a letter from your treating medical practitioner  indicating the medical condition requiring treatment.

* subject to maximum policy limits and sub-limits for your extras cover type, and any applicable waiting periods.