Claiming prescriptions, injections and vaccinations

Looking after your health often means accessing prescriptions, injections and vaccinations. If you hold an eligible Extras Cover and have served the two month waiting period, you may be able to claim a benefit towards the cost of some of these pharmaceuticals. Your Policy Summary will provide detailed information on your level of benefit and any limits that may apply.

We have put together some helpful information about our prescriptions, injections and vaccinations benefit, eligibility criteria and how to make a claim.

What is covered?

When the Prescriptions, Injections and Vaccinations benefit is included on your Extras Cover and you have served the two month waiting period, you may be able to claim a benefit for eligible pharmaceuticals. To be eligible for a benefit the prescription, injection or vaccination must meet the following criteria:

  • Pharmaceutical must be prescribed or administered by a medical practitioner
  • Pharmaceutical must be a category S4 or S8 item (prescription-only medicine or controlled drug)
  • Pharmaceutical must cost more than the PBS co-payment of $41 (effective from 1 January 2020)
  • Pharmaceutical must not be subsidised by the Pharmaceutical Benefits Scheme (PBS). You can read more about the PBS here
  • Pharmaceutical must be approved by the Therapeutic Goods Administration (TGA) for supply and sale in Australia. The TGA is in charge of regulating medicines and vaccines, as well as other products that relate to your health.  You can read more about the TGA’s role here

If the above criteria are met, then a benefit for the amount which exceeds the PBS co-payment is available, up to relevant item limits and annual group limits.

What isn’t covered?

Unfortunately, there are certain prescriptions, injections and vaccinations that Westfund is unable to pay benefits towards. These include:

  • Medicinal preparations not prescribed or administered by a medical practitioner
  • Pharmaceuticals subsidised by the Pharmaceutical Benefits Scheme (PBS)
  • Pharmaceuticals that cost less than the standard PBS co-payment of $41 (effective from 1 January 2020)
  • Pharmaceuticals not approved by the Therapeutic Goods Administration (TGA) for supply or sale in Australia. This may include compounded medications (where one ingredient does not have approval), Special Access Scheme items as well as experimental and clinical trial prescriptions
  • General use contraceptives, anabolic steroids or cosmetic injections (e.g. botox). However, when the use of these items is prescribed specifically for the treatment of a medical illness, we can pay benefits on receipt of a supporting letter from your prescribing medical practitioner
  • Claims provided with unclear or incomplete receipts. If this happens to you, we’ll be in touch to see if we can resolve the issue.
  • Pharmaceuticals that may be supplied to you during an inpatient hospitalisation
  • Pharmaceuticals that can be purchased without a prescription

Making your claim

The easiest and quickest way to make your claim is via the Westfund app. However, we provide several other options (online, by mail or email) to submit your claim so you can select the way that suits you best. You can download a claim form here.

Please ensure your receipt/s include the following information:

  • supplier details (name of pharmacy or doctor’s name)
  • patient details
  • supply date
  • name of pharmaceutical
  • individual costings
  • any amounts paid or outstanding.

An ‘Official Pharmacy Receipt’ is required when purchasing items from a pharmacy. In addition to the above information, these receipts must also include:

  • prescription number
  • prescriber name
  • prescriber number
  • indication that it’s a Private, Non-NHS or Non-PBS item.

We’re here to help

As always, if you have a question about a claim or any item, we are on hand to help.

Please get in touch by calling 1300 937 838 or via email to enquiries@westfund.com.au

Photo by Laurynas Mereckas on Unsplash