Pharmacy claims and health insurance

We won’t pay any benefits toward:
• Pharmacy items that are already subsidised by the PBS
• Non-PBS pharmacy items that cost less than the co-payment amount
• Oral contraceptives (unless they’re prescribed for purposes other than contraception)
• Prescription pharmacy items prescribed for cosmetic purposes
• Non-TGA Approved items
• Any pharmacy items without a prescription
• Herbal medicines
• Vitamins
• Any over the counter items
If in doubt, chat to your pharmacist and doctor about whether your pharmacy item is eligible for benefits. If it meets the criteria above and is not appearing in the search you can submit your claim for manual assessment. Simply select the Claim Form option on the upload documents page and attach both your Claim Form and your receipts. You can also send your forms by post to Locked Bag 4, Wetherill Park NSW 2164.
Message us if you get stuck or have any questions.

Private health insurers are prohibited by legislation to pay benefits towards medications that have been subsidised by the PBS.

No, you can’t claim over the counter medications that are available without prescriptions. You can only claim for prescription medications that meet the criteria above under ‘What medications can I claim’.

To make a claim for pharmacy benefits, you must have a receipt from a pharmacy or Medical Practitioner containing:

• Script No (required only for claims dispensed from a pharmacy)
• Patient name
• Type of drug including name, form, dose (strength) and quantity of the drugs dispensed
• Date of dispensing or supply
• Cost per pharmaceutical item
• Prescribing doctor’s/approved provider’s details or immunisation program provider (in the case of vaccines) and their prescriber number.

Before we pay any benefits, you must cover the general patient PBS co-payment. This means that we will pay benefits towards pharmacy claims for any portion of the cost above the general patient PBS co-payment, up to the maximum benefit amount on your product.
You can check your member guide to see the maximum benefit you can claim per item on your pharmacy products. Please note, the general PBS co-payment amount changes each year on 1 January. In 2026, the PBS co-payment is $25.
If pharmacy is included on your cover, an annual limit applies. You may also be subject to waiting periods. Check your product guide for more details on this and your eligible benefit amounts.