Is It Normal That The Pharmaceutical Benefits Scheme (PBS) Calculated on Per Item?

goliath on 06/09/2024 - 23:42
Last edited 07/09/2024 - 09:30 by 1 other user

I've got a private health insurance that covers pharmaceutical medicine for me and my family.

Recently I ordered some prescription of myopia eye drops for my child. It's 3 bottles, about $30 each, plus the $12 delivery, which was 30*3+12 = $102 in total. It's in a same prescription, same receipt. When I tried to claim it, my insurance provider says the PBS was calculated on per item, which is $31, just slightly more than the per item price. And they don't cover delivery. So I get nothing claimed out of that $102.

Is it normal? I remembered when I was with my previous provider (Bupa) it was calculated on the total price, not per item. Setting it to per item makes it almost useless, as not many usual single presciption item is above $31.

Health & Beauty Medicine

Comments

  • May4th on 07/09/2024 - 00:01

    you need to ask for it to be put on the same script, ie. one bottle + 2-5 repeats on a reg 49 script, and when you fill the script ask for all of it at once. then each item will be $102

    • goliath on 07/09/2024 - 02:43

      It's on the same script. It's showing single item price, and the number of items, and the total price at the same time. Like the receipt you get when you buy 3 TimTams from Woolies.

  • thedeep on 07/09/2024 - 00:02

    It depends on how it is written on the receipt. If it is written so that it looks like a single fill of the script with 1 medicine given to you (with that being equivalent to 3 bottles), then that's what will be used. If it is an itemised receipt which makes it look like you received 3 things, it is usually applied individually.

    Potentially you might have had a different outcome with a different chemist (ie depending on how they have written the receipt).

    • goliath on 07/09/2024 - 02:45

      Thanks. I guess it's hard to ask them to just 'merge' the items into one. Hmmm…

  • MS Paint on 07/09/2024 - 01:17
    +1

    Yes it's normal. PHI will generally not cover any medication that has some sort of pbs inclusion.

    Read your PHI PDS for the exact wording.

    PHI funds aren't exactly generous when it comes to pharmaceuticals. The list of exclusion is huge, the payouts are capped and in some cases waiting periods apply. In other words - useless.

    • goliath on 07/09/2024 - 02:49
      -3

      I've read it, it's just saying

      Pharmaceutical benefits
      Depending on your level of cover, eligible pharmaceuticals are covered
      in line with your extras benefit limits after you’ve paid a sum equal to the
      Australian Government’s highest, current Pharmaceutical Benefits Scheme
      (PBS) co-payment charge. You must provide an official pharmacy itemised
      invoice or account/script with the claim.
      In order to receive a benefit, the script must:
      ■ include the drug name, strength and quantity
      ■ include the supply/dispensed date
      ■ be for a prescription item that’s approved under the government’s
      PBS
      ■ cost above the current PBS amount
      ■ include the patient’s and prescribing doctor’s name
      ■ include the pharmacist’s name, address and prescription number.
      Weight loss medication and body enhancing medications (e.g. anabolic
      steroids and erectile dysfunction drugs) aren’t covered unless they’re
      prescribed for the indication by your specialist for treatment of a medical
      condition or ailment and/or specifically included under your level of cover.
      Please contact your Member Relations Team for the latest PBS
      threshold or refer to the Department of Health website at health.gov.au

      Tbh I didn't see where it says that the PBS is calculated on per item. I made a complaint to them but was useless

  • Dollar General on 07/09/2024 - 06:26
    -4

    How is the CEO or directors of these companies going to be able to afford to send their kids to elite private schools, holiday in the European summer etc if they make their products benefit the consumer?

  • AustriaBargain on 07/09/2024 - 06:41

    My medical cannabis, which I absolutely need to live, isn't even on PBS. I have to pay the full amount for this vital medicine, plus shipping.

    • Bruceflix on 07/09/2024 - 07:03

      Cheaper to buy from bikies

      • Mike444 on 07/09/2024 - 07:10
        +1

        Considering you can can legally buy 15g for $88. I highly doubt that.

        • AustriaBargain on 07/09/2024 - 08:17
          -1

          Where? I'm paying $140 including postage for 10g for Amethyst 25 (25% THC) from Tasmanian Botanics. And it's fine, it smells and tastes good, the bikie cannabis smells and tastes like cat piss.

  • JimmyF on 07/09/2024 - 09:40
    +6

    And they don't cover delivery.

    PBS covers drugs, not delivery. Having them delivered was your choice.

    PHI will cover drugs not covered as part of the PBS.

    So I get nothing claimed out of that $102.

    Sounds correct to me.

  • freefall101 on 07/09/2024 - 19:07
    +1

    The PBS price is $31, you paid $30 which is under the PBS price, so you get nothing back. It's only what you pay over the PBS price you're covered on.

    I don't see why buying in multiples would change that, the PBS price is usually done on the size as well.

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