Pharmaceutical Benefits Guide

Extra support

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

The PBS is 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 except when they are supplied while an in-patient of a hospital.

Emergency Services Health’s pharmaceutical benefits cover a wide range of items that require a prescription when dispensed from private recognised pharmacies, Australia-wide.

Emergency Services Health doesn’t restrict you to a limited list of prescribed items or direct you to particular pharmacies before you can claim pharmaceutical benefits.

You can go to any private pharmacy to have your prescription dispensed and still be able to claim pharmaceutical benefits on eligible prescription items.

All you need to do when you receive your prescription items is ask the pharmacist for a detailed receipt or tax invoice that also describes the prescription items supplied to you and then submit a claim to Emergency Services Health along with the receipt or invoice.

Emergency Services Health will refund your cost over and above the first $23, up to a maximum pharmaceutical benefit of $60 per prescription item supplied. Some simple conditions apply.

Which prescriptions are covered?

There are a multitude of rules which cover the dispensing of prescriptions. However, for simplicity we’ll divide them into two categories, Group 1 (PBS) and Group 2 (Non PBS).

Group 1 (PBS)

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

This subsidy is paid direct to the pharmacy by the Government. Health Funds are not permitted to pay benefits towards government subsidised items.

Group 2 (Non PBS)

Non PBS items cover virtually all prescription items other than those listed in the PBS. Some common Non PBS items include some asthma medications, antibiotics and contraceptive pills. Non PBS items attract Emergency Services Health Pharmaceutical benefits.

Conditions

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

• You must pay the first $23 towards each prescription item supplied.
• The maximum Pharmaceutical benefit paid by Emergency Services 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 Emergency Services Health’s unique Rollover Benefit.
• For prescriptions dispensed in quantities greater than the minimum standard packaged quantity (as determined by Emergency Services 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, Emergency Services Health will be unable to pay a Pharmaceutical benefit, and this includes restricted and authority required prescription items.*

*For a prescription item appearing on the PBS list with a restriction or authority requirement for subsidy on the PBS, Emergency Services 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 Emergency Services 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/homeor ask you pharmacist when filling your script.

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

If you have any questions do not hesitate to contact Emergency Services Health on 1300 703 703