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Pharmacy Cover Frequently Asked Questions

The following information may not apply to you if you are claiming as an overseas visitor.

What is pharmacy cover?

Bupa provides cover for both inpatient pharmacy (medication provided to our members when they are admitted to hospital) and out-patient pharmacy (medication purchased by a member while not a Hospital inpatient.). They are covered and claimed for very differently, the former falling under our member’s hospital cover, the latter falling under our member’s Extras cover. Your eligibility for benefits will depend on the level of cover that you have chosen.

Find out more about claiming inpatient pharmacy
Find out more about claiming out-patient pharmacy

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Am I covered for pharmacy?

You may be able to claim for a range of prescribed pharmacy items, depending on your level of Hospital or Extras cover, through our Pharmacy claims process

Hospital Cover:

Bupa’s range of Hospital coverage includes cover for medications provided to our members while they’re admitted as an inpatient at any of our Members First or Network Hospitals in Australia. In most circumstances, the hospital will bill Bupa directly. You will be covered for most pharmaceutical items including Pharmaceutical Benefits Scheme (PBS) gap items that are used for inpatient services. We also contribute to the services. We also contribute to the cost of some High Cost Drugs (HCD) however only when approved by the Therapeutic Goods Administration (TGA) for the condition to be treated. Discharge pharmacy however is not covered - this is considered to be any medication the treating medical officer has prescribed for their patient which has not been opened at the time of discharge.

Extras Cover:

With our range of Extras covers you can claim for prescription items that you have not received through any Government funding scheme including the Pharmaceutical Benefits Scheme (PBS) - , provided their usage is approved by the Therapeutic Goods Administration and they are not on our Exclusions list.

Before we pay a benefit for eligible pharmacy items we deduct the PBS Co-payment amount from the amount you have paid. This means that if the cost of the drug is less than the PBS Co-payment amount, a benefit will not be paid. As at January 2016, this amount was $38.30.

Some pharmacy items are only covered while not a Hospital inpatient. For more information on this, please refer to our Important Information Guide.

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Inpatient pharmacy – what am I covered for?

If you are an inpatient of a Members First Provider, Network Hospital, Fixed Fee day or overnight facility you will be entitled to the following benefits.

You are covered for all supplied pharmaceuticals approved by the Pharmaceutical Benefits Scheme (PBS) providing:

  • you have chosen Bupa hospital coverage and that your membership payments are up-to-date
  • you are not currently serving any waiting periods, and
  • medications are supplied as part of your in-hospital treatment.

In addition, as a Bupa member you will be covered for all High Cost Drugs (HCD) prescribed for immediate life-threatening events which are not listed on the PBS but approved by the TGA for specific conditions and are supplied to a member as an inpatient. This excludes any compound items or experimental drugs.

Other High Cost Drugs (HCD), prescribed in non life-threatening situations, may be charged according to the current Hospital Agreement in place with Bupa. For further information please contact 134 135.

Unopened drugs upon discharge

You may be charged for any prescribed unopened drugs provided to you when you are discharged from hospital. Unopened pharmaceutical items, including prescriptions provided upon hospital discharge are at the expense of the patient and not the hospital. You are not able to claim these drugs under your Hospital cover, but you may be eligible to claim them under your Extras cover.

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Inpatient pharmacy – how do I claim?

In most cases, inpatient pharmaceuticals are covered wholly by the hospital agreement (for Members First, Network, Fixed Fee day and overnight facilities) – so you won’t even see an invoice, and won’t have to claim for these.

Please note:

  • All waiting periods need to have been served, and your membership payments must be up-to-date at the date of receiving the medications.
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Out-patient pharmacy – what am I covered for?

Bupa provides cover for an extensive range of medications.

If you have Extras cover with Bupa which includes cover for pharmacy, you are entitled to claim medications that meet the following requirements:

  • Category S4 or S8 items (that is, prescription only medicines or controlled drugs)
  • Prescribed by an Australian registered medical practitioner, dentist or nurse.
  • Either supplied by a registered pharmacist, recognised by Bupa, in private practice in Australia, or administered at a Bupa recognised Australian vaccine clinic
  • Approved by the Therapeutic Goods Administration for sale within Australia
  • The medication is not otherwise supplied under or funded by a public arrangement or scheme, including the Pharmaceutical Benefits Scheme (PBS)
  • Is not on Bupa’s Exclusions List and
  • Is not otherwise excluded by Bupa (contact us for further information).

Please note:

  • All waiting periods need to have been served, and your membership payments must be up-to-date at the date of receiving the medications.
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Out-patient pharmacy – how do I claim?

Out-patient pharmaceuticals are prescribed drugs or pharmacy items that you may need to purchase when you are not in hospital. Depending on the level of Extras cover you have, you may be eligible to claim a benefit from Bupa.

What do I need to make a claim?

You will need to ensure you receive the official pharmacy receipt from your pharmacist when purchasing your medication, and submit a receipt for each claim. Official pharmacy receipts should show the following information:

  • Drug name
  • Date dispensed/supply date
  • Strength
  • Quantity
  • Confirmation that the medication was not subsidised by the Australian Government (PBS)
  • Pharmacist’s name, address and prescription number
  • Customer’s name and address
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Where can I make a claim?

Visit a Bupa centre:

If you want to make a claim at a Bupa centre, you will need to bring your membership card together with your official pharmacy receipt with you. Our friendly Bupa team will be able to assess your benefit and process your claim for you.

Find a Bupa centre

Post your claim:

Or you may post your completed claim form and pharmacy receipt to:
Bupa Reply Paid 990
Adelaide SA 5001

Call us:

Or you can call us on 134 135 for more information.

What items are not covered?

Items not covered by your Hospital or Extras cover include the following:

  • Non-prescription medicine
  • Any non-TGA approved items
  • any PBS listed items which have been supplied under the PBS (for out-patients)
  • Any compounded or experimental drugs
  • Any items listed on Bupa’s Exclusions List
  • Any item listed under the Alternate PBS arrangement list
  • Natural remedies
  • Anabolic Steroids
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What is the Therapeutic Goods Administration (TGA)?

The Therapeutic Goods Administration (TGA) is a division of the Department of Health and Ageing and is responsible for regulating therapeutic goods including medicines, medical devices, blood and blood products. If the TGA is satisfied that a medicine in its registered form meets its standards for manufacturing quality, safety and effectiveness in treating a particular illness, it will approve it for sale in Australia, and you may be eligible to claim a benefit from Bupa.

If an item is non-TGA approved, it will not be covered by Bupa.

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What is a non-TGA approved item?

The Therapeutic Goods Administration (TGA) is part of the Commonwealth Government Department of Health and Ageing. The TGA's overall purpose is to protect public health and safety by regulating therapeutic goods, including medicines that are supplied either imported or manufactured, or exported from Australia. The TGA is responsible for ensuring that medicines available for supply in Australia are safe and fit for their intended purposes.

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What is the Pharmaceutical Benefits Scheme?

The Pharmaceutical Benefits Scheme (PBS) is a government initiative, which subsidises the cost of medicine for Australians. Most of the medicines covered by the scheme are dispensed by pharmacists and used by patients at home.

If a drug is not-PBS listed (i.e. Private prescription), and you have a level of cover that includes pharmacy benefits, Bupa may pay a benefit provided it is approved by the TGA.

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What is the PBS Co-payment fee?

Bupa’s extras products require the deduction of the PBS Co-payment amount from the cost of a pharmacy item before benefits are payable. This means that if the cost of a prescribed medication is less than the PBS Co-payment fee, you will not be able to make a claim because this cost is deemed to be your co-payment. From 1 January 2016, you may pay up to $38.30 for most PBS medicines or $6.20 if you have a concession card. The Australian Government pays the remaining cost.

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Why can’t I make a claim for a non S4 or S8 prescription that my doctor gave me (eg Combantrin suspension?)

Bupa will only pay for prescription medicines which are classified as S4 or S8 category medications.

In Australia medicines are grouped into 'Schedules' according to the control over access and availability required to ensure the public’s safety.

Medicines are grouped into the following schedules:

  • Schedule 2 (S2) – Pharmacy Medicine – only available from pharmacies (some advice for safe use is required)
  • Schedule 3 (S3) – Pharmacist Only Medicine – must be supplied by a pharmacist – safe use requires professional advice – pharmacist usually records the name and address of the purchaser.
  • Schedule 4 (S4) – Prescription Only Medicine – these medicines should only be obtained from a pharmacist with a prescription from a doctor, dentist or nurse.
  • Schedule 8 (S8) – Prescription only Controlled Drug – these can only be obtained with a prescription from a doctor as they are drugs of addiction and therefore contain restrictions around their supply.

Bupa only pays benefits for Schedule 4 (S4) and Schedule 8 (S8) medicines.

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What is a non-PBS drug?

If the government elects not to subsidise a medicine under the Pharmaceutical Benefits Scheme but it has been approved by the TGA for sale, it is considered to be a non-PBS drug/Private Prescription.The government might choose to do this because:

  • an alternative medicine for the same condition currently exists and is subsidised
  • the cost of the medicine is too great and, in the government’s opinion, unsubstantiated
  • the medicine has been proved to not work as well or better than an already listed PBS medicine for that particular condition.
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What is the Alternate PBS Arrangement List?

Alternate arrangements exist for certain items including:

  • Methadone programs
  • Human Growth Hormones
  • Highly Specialised Drug programs
  • Special Authority Program
  • IVF Gift Program.
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Can I claim for travel vaccinations?

Benefits are payable for travel vaccinations administered by a doctor or at a vaccine clinic if the member provides a pharmacy receipt, doctors account or a vaccine clinic account (ie. naturopaths excluded).

Benefits are payable providing the member holds the appropriate extras cover, the vaccine is an S4 or S8 item, not included on Bupa's Exclusions List, and costs more than the PBS Co-payment amount.

Examples include:

  • Meningococcal Vaccines
  • Chicken Pox Vaccine
  • Travel Vaccines
  • Some Allergy medications
  • Hepatitis B/Hepatitis A.
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