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 HCi approved prescription medications for members with HCi private health extras cover.

What is the PBS?

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

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 the PBS subsidises.

Because we can’t determine whether individual HCi members are eligible for the PBS subsidy, medications 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 is 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 some of the costs through pharmacy claims.

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. Then you 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 need to provide HCi each time with an official pharmacy receipt that proves the PBS didn’t cover your medication. Note you may need to specifically request this from your pharmacist as it is different to a normal pharmacy tax invoice or receipt. Your official pharmacy receipt must show

• the full name of the patient
• script number
• prescribing doctor information, including provider number
• cost paid
• name of medication
• dispensed date.

What are HCi-approved pharmacy claim items?

To qualify as an HCi approved pharmacy item under eligible HCi extras cover, your prescription medication 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 vapes and vape products (whether recreational or therapeutic), 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 a 12 month waiting period for medicinal cannabis.

In some instances, such as for medical Botox and medicinal cannabis prescriptions, we may also require your treating medical practitioner to complete our medically eligible declaration indicating the medical condition requiring treatment.

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