Pharmaceutical Benefits Guide

How private health insurance covers Non-PBS costs

Under our Rolling Extras cover or Gold Combined cover you’re eligible to receive pharmaceutical benefits towards prescription items that aren’t eligible for subsidy under the Government’s Pharmaceutical Benefits Scheme (PBS).

These are called Non-PBS, and don’t fall under the PBS - an Australian Government subsidy scheme that lowers the cost of prescription medicine.

Health funds are not permitted to pay benefits towards medicines that receive a government subsidy.

How to claim Non-PBS medications

For claiming purposes, ask the pharmacist for a a health fund receipt which contains;

The pharmacist's details
Prescribing doctor
Date dispensed
Script number
Patient
Description of pharmacy item

Then, submit a claim via the Police Health app (Google Play/App Store) by uploading your receipt or invoice.

Police Health Pharmacy Benefits and Conditions

Police Health’s Extra’s cover includes a Pharmacy Benefit with an Annual Maximum of $600 per person, or Rollover Maximum of $1200 per person.*

To provide for a fair distribution of Pharmaceutical benefits we’ve established the following requirements*:

You must pay the first $23 towards each prescription item supplied.
The maximum Pharmaceutical benefit paid by Police Health per prescription item supplied is $60.
The maximum Pharmaceutical benefits paid per person per calendar year is $600, but may be higher (up to $1200) where members are eligible for Police Health’s unique Rollover Benefit.
For prescriptions dispensed in quantities greater than the minimum standard packaged quantity (as determined by Police Health), the initial member cost of $23 may increase.
Waiting periods (2 months) may apply to Pharmaceutical benefits for new members or members upgrading cover.
Pharmaceutical benefits will only be paid for items that require a prescription for their supply and, for almost all items, they must be supplied through a pharmacy.
Excludes medication ordinarily available without a prescription, including where the medication is recommended, ordered, prescribed or supplied by a doctor.
Once the government lists a prescription item for subsidy on the PBS and when the medication meets the PBS subsidy criteria for the patient, Police Health will be unable to pay a Pharmaceutical benefit. This includes restricted and authority required prescription items.*
Items must be dispensed from a Recognised Pharmacy

*For a prescription item appearing on the PBS list with a restriction or authority requirement for subsidy on the PBS, Police Health may pay a Pharmaceutical benefit for the supply of the prescription item where the person does not meet the restriction or authority requirements.

Please note, changes within the PBS list occur frequently, where items previously covered and not covered change.

This may affect Police Health Pharmaceutical benefits where items you may claim now may not be eligible for claims in the future and vice versa.

For the most up to date PBS list visit http://www.pbs.gov.au/pbs/home or ask you pharmacist when filling your script.

PBS vs Non-PBS: Understanding the Difference

PBS medications

PBS items are those listed for a Government subsidy towards their cost.

The government pays the subsidy to the pharmacy. Health Funds are not permitted to pay benefits towards government subsidised items.

Non-PBS medications

Non-PBS items cover most prescription items other than those listed in the PBS.

Some common Non-PBS medications include some lifestyle and cosmetic, over the counter and certain specialist medications.

Non-PBS items attract Police Health Pharmaceutical benefits.

How does a medication be on the PBS list?

The Therapeutic Goods Administration (TGA) approves a medicine for use in Australia before it qualifies for the PBS.

The sponsor of the medicine, usually a pharmaceutical company, makes this application.

To sell it in Australia, they apply to the TGA to have the medicine included in the Australian Register of Therapeutic Goods (ARTG).

The sponsor must provide evidence the medicine meets the required standards of quality, safety and effectiveness for the intended use.

It’s important to note that that some medicines may be for many conditions.

PBS approval process

The pharmaceutical company applies to have their medication listed on the PBS.

The Pharmaceutical Benefits Advisory Committee (PBAC) considers the applications for the PBS listings. The PBAC is an independent expert body appointed by the Australian Government.

The PBAC must make a positive recommendation for a new medicine to be on the PBS.

They look at the cost and clinical effectiveness of the medicine when compared with other treatments for the same condition.

The PBAC also requires pharmaceutical companies to include;

Information about the new medicine and the medicine or treatment it is being compared to
Evidence from clinical trials
An economic evaluation
An estimate of the impact of supplying the medicine on the (Federal Government) budget.

Cost implications and how patients save

The PBS has many examples that show how it helps Australians save on medications.

That includes the 2022 expansion of the of the PBS listed pembrolizumab (Keytruda^®).

Pembrolizumab is an immunotherapy which works by helping the immune system fight certain cancers.

It's used to treat patients with squamous cell carcinoma of the head and neck.

With subsidy, this treatment costs patients less than $50.

Without subsidy, patients pay more than $135,000 per course of treatment.

In 2022, around 5,100 Australians were diagnosed with head and neck cancer (including lip).

Navigating Non-PBS Medications: A Guide for Patients

How to find affordable Non-PBS medications

The extra cost of Non-PBS medications is frustrating, but there are ways you can lower the cost.

You should talk to your doctor or health professional before considering any of the below.

Life Saving Drugs Program (LSDP)

The LSDP pays for essential medicines to treat ultra-rare and life-threatening diseases. It covers medicine if;

They are clinically effective, but not cost effective enough to list on the PBS
They treat life threatening and ultra-rare conditions. This is defined as 1 case per 50,000 people or fewer in the Australian population
The pharmaceutical company (sponsor) applies for an LSDP listing.
For more information and to see if you’re eligible, visit the Federal Department of Health’s website.

Shop around

It can be worth shopping around because different pharmacies may charge different prices. Even if the differences are small, this will help you save a lot of money over the long term.

Ask for the generic version

Did you know you can ask your doctor to prescribe a generic medicine? You can also ask your pharmacist if they have a more affordable brand of the same medicine.

Understanding your pharmaceutical script: PBS vs Non-PBS

Reading PBS and Non-PBS medication scripts

Understanding your pharmaceutical script is essential to managing your medications and knowing what costs to expect. Here's a simple guide:

Your script will list the medication name (often its generic name) and the prescribed dose. It may also include usage instructions, such as "take one tablet daily."
Look for "PBS" noted on the script or ask your pharmacist if it's eligible. Non-PBS options are mostly used when no equal PBS-listed drug is available.

The importance of keeping accurate records of your medication history

It's important that you have accurate records of your medication history. It's vital to have safe and effective healthcare.

This helps manage your treatment and avoid associated risks.

Why it’s important:

Avoid duplications or harmful interactions between medications
Ensures emergency healthcare providers know what you’re taking
Provides health professionals with valuable insights into your treatment,

What to Include in Your Records:

Medication names, doses, and usage instructions
Start and stop dates for each medication
Any side effects or allergies you’ve experienced.

Use a notebook, digital app or a pharmacy printout to keep these records.

Claiming vaccines

If you have our Rolling Extras cover or Gold Combined cover, you can claim vaccines if they meet specific criteria.
Eligible vaccines must be;

Prescribed
Supplied by a registered pharmacist in a private practice. Or by a registered medical practitioner who's allowed to dispense pharmaceuticals.
Not be government subsidised

You can also claim vaccines that need a prescription but are not listed on the PBS. This includes travel vaccines and other non-PBS-subsidised immunisations.

How to claim

Request a detailed receipt or tax invoice from the pharmacist or medical practitioner.

This documentation should include the description of the vaccine supplied. Submit the claim along with the receipt to Police Health via our app.

Important - Vaccines purchased from councils or other government-run clinics are not eligible for reimbursement.

This benefit guide is only intended as a brief outline of our Pharmaceutical benefits.

If you have any questions do not hesitate to contact Police Health on 1800 603 603.

*All benefits may be subject to Waiting Periods, Limits and other conditions. Rollover applies once you’ve completed your first 12 months membership (2 years for Major Dental). Providers must be recognised by us. Review the cover tables on the Combined, Hospital and Extras pages, and your State Premium and Benefit Guide or contact us for more information.