title: A survey of reimbursement practices of private health insurance companies for pharmaceuticals not covered under the Pharmaceutical Benefits Scheme 2008.
abstract: OBJECTIVE
  To describe the current practices and policy of Australian private health insurance (PHI) companies with respect to cover for pharmaceuticals not subsidised under the Pharmaceutical Benefits Scheme (PBS).
  
  
  METHODS
  A 2008 review of web-published policy statements for top-level hospital and comprehensive general treatment insurance, and survey of reimbursement practices by way of questionnaire, of 31 Australian-registered, open-membership PHI companies.
  
  
  METHODS
  Description of the level of pharmaceutical cover and important considerations identified by PHI companies for funding non-PBS pharmaceuticals through benefit entitlements or ex-gratia payments.
  
  
  RESULTS
  Nine of thirty-one PHI companies (29%) provided responses accounting for ~60% market share of PHI. The majority of smaller PHI firms either declined participation or did not respond. The maximum limits offered for non-PBS pharmaceuticals, under comprehensive general treatment insurance, varied significantly and typically did not adequately cover high-cost pharmaceuticals. Some companies occasionally offered ex-gratia payments (or discretionary payments in excess of the policyholder's entitlement benefits) for high cost-pharmaceuticals. Factors considered important in their decision to approve or reject ex-gratia requests were provided. All results were de-identified.
  
  
  CONCLUSIONS
  There is little consistency across PHI companies in the manner in which they handle requests for high-cost pharmaceuticals in excess of the defined benefit limits. Such information and processes are not transparent to consumers.
authors: Pharmacy Department, Peter MacCallum Cancer Centre, St Andrew's Place, Melbourne, VIC 3002, Australia. senthil.lingaratnam@petermac.org
authors: Senthil M
authors: SM
authors: Lingaratnam
authors: Sue W
authors: SW
authors: Kirsa
authors: James D
authors: JD
authors: Mellor
authors: John
authors: J
authors: Jackson
authors: Wallace
authors: W
authors: Crellin
authors: Michael
authors: M
authors: Fitzsimons
authors: John R
authors: JR
authors: Zalcberg