External Breast Prostheses Benefit Guide

Did you know that you can claim from Emergency Services Health and Medicare when purchasing an External Breast Prostheses?

It’s uncommon to be able to claim from both in Australia, so we wanted to make your aware and show you just how.

Why choose a prostheses?

Emergency services workers are at greater risk of breast cancer, 1 in 7 women are diagnosed with breast cancer in their lifetime, and about 1 in 500 men are diagnosed in their lifetime.

Treatment for early or locally advanced breast cancer will usually include surgery, either a breast-conserving surgery or a mastectomy.

Following surgery, a breast prostheses can be worn, and is a synthetic breast or part of a breast worn under clothing or in a bra to replace all or part of your breast.

The Cancer Council says that there are many reasons to choose a breast prosthesis after a mastectomy including:

• Wanting to replace the weight of the lost breast
• Creating symmetry when wearing clothing
• Helping to restore self-esteem and confidence
• Helping to cope with the experience of cancer
• Taking control of your appearance

Where can you buy them?

You can get a breast prosthesis from several retail outlets, including:

•  Department stores
• Specialist stores
• Australian online store

If you want to visit a store to purchase a prostheses, it may be a good idea to phone first and make an appointment with the prosthesis fitter. 

If you are purchasing a prosthesis from a website, it is important to remember that you may not be able to have it fitted properly by a specialist fitter.

Some organisations offer a mobile service where they bring a variety of breast prostheses to you, so you can try them in the privacy of your home. 

You can shop around before purchasing your prosthesis as they can vary in terms of quality and price. Breast Cancer Network Australia says that an external breast prosthesis is best fitted by an experienced breast care nurse or an accredited breast prosthesis fitter.

How much do they cost?

The cost of a breast prosthesis and bra varies depending on the type, which may influence your choice. 

They usually cost between $300 and $500 and generally need to be replaced every two years.

Who can claim and how much do we pay?

Emergency Services Health members with Gold Hospital cover or Gold Combined cover can claim*, however there are some important things to remember;

• There’s a 12 month waiting period
• We pay up to 80% of the charge, up to $300 per person
• This combined limit applies to the right and to the left external breast prostheses
• Members can claim 1 replacement every 24 months from the last date of service, and replacement period applies separately to the right or to the left external breast prosthesis
• Medical practitioner letter or referral may be required, unless your claims history shows that you have had a mastectomy previously

*Information correct as of Friday 10 November 2023, other conditions apply

How do I claim it through both Medicare and Emergency Services Health?

Simple, make a claim through Emergency Services Health first, and then claim through Medicare if there are any remaining costs.

Example 1 – Trish

Trish had a mastectomy. She bought her prostheses for $375 and gets $300 back from Emergency Services Health. 

Then Trish makes a claim with Medicare by completing the External Breast Prostheses Reimbursement Program form (NH005) and gets another $75 back. 

This $75 is the difference between the cost of her prostheses and what we paid her, meaning Trish didn’t have to pay for her breast prostheses.

Do we cover bras specific to prostheses?

Yes, Emergency Services Health members with Gold Hospital cover or Gold Combined cover can claim for an External Breast Prostheses Bra.

There are important things to remember though;

• There’s a 12 month waiting period
• We pay up to 80% of the charge, up to $100, and there’s a limit of 3 bras per person per calendar year
• We don’t pay for night-attire or bathers
• Medical practitioner letter or referral may be required, unless your claims history shows that you have had a mastectomy previously

We hope this has helped, and if you’d like more help please call us on [1300 703 703).