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Private Health Insurance – Pharmacy Extras (Ancillary) Cover – In Desperate Need of Shake-up

Sinapse - Private Health Insurance - Pharmacy Extras (Ancillary) Cover - In Desperate Need of Shake-up - News

When a patient presents at a pharmacy with a private prescription, not covered by the PBS, most patients are disappointed by the benefits they receive under their ancillary benefits private health insurance cover, and an alarming number don’t even know they have pharmacy extras (ancillary) cover.

With up to 90 cents from each dollar spent on premiums paid to healthcare providers an industry expert claims pharmacy extras coverage is cross subsidising other health services. To make matters worse Health Minister Sussan Ley has flagged abolishing the 30 per cent rebate on ancillary cover that ensures services such as pharmaceuticals, dental, physio and optical care leaving the strong indication that government rebates with only cover hospital costs. Over $17 billion a year is spent covering private health treatments.

With this in mind, Senior Health Strategist at Sinapse Kos Sclavos, who has developed a number of patient support programs covering private prescription medicines, is calling for the pharmaceutical industry to have a coordinated approach to the latest Commonwealth Government heath review on private health insurance.

On Wednesday Health Minister Sussan Ley announced a public consultation to seek consumer feedback on private health insurance. Under the review the Department of Health will be conducting a series of roundtable discussions with key industry and consumer representatives. Furthermore, Professor Graeme Samuel, the former Chairman of the Australian Competition and Consumer Commission, will be working with the Department of Health, to provide his technical expertise to these industry consultations.

“The pharmaceutical industry needs to come together to ensure we have a unified approach, and then approach the Government review with a formed policy to establish a viable private prescription market that does have Government support, including maintenance of the 30% rebate,” Mr Sclavos stated.

“We have a pharmacy extras coverage structure which varies greatly across health providers. We have a plethora of different models which are not understood by doctor or pharmacists leading to patients not being given appropriate advice. We have a private health insurance sector which does not give support tools to health professionals or patients to explain benefits. We have caps per prescription in terms of pay out benefits, and we have caps per year per specific ancillary benefit. Patients are not getting value for money.”

“Australia needs a viable private prescription funding model. The pharmaceutical industry in Australia needs a coordinated approach to the review of private health insurance to ensure a viable private prescription market is established in Australia. The sector should be seeking its own roundtable discussion with the chair Professor Graeme Samuel,” added Mr Sclavos.

“In addition some health funds cover specific professional pharmacy programs that may assist with medication compliance and persistence. There is no national, widely available programs, which can be taught at the University sector and accessed through national education providers.”

“Health funds should invest in professional pharmacy programs, within the ancillary pharmacy extras cover, that maximise medication compliance and concordance. It is in the interest of the health fund that this occur,” added Mr Sclavos.

Sinapse Pty Ltd provides tailored, IT enabled, private prescription patient support programs, for pharmaceutical manufacturers, through 2,600 community pharmacies across Australia.

Sinapse works with leading global health and pharmaceutical companies on their business strategy, business optimisation and systems implementations. The depth of experience includes retail and hospital environments, wholesale distribution providers and originator and generic pharmaceutical companies.

Click here to view the Minister’s speech at the Press Club, where the health insurance review was announced.

Media contacts:
For further information please contact Kos Sclavos, Senior Health Strategist Sinapse Pty Ltd on 0415 879 830 or

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