With the Australian medical cannabis landscape evolving, it’s hard for patients to keep tabs on the most current information around coverage, rebates and government support for their care. With limited access to financial support, the decision for patients to explore medical cannabis has been a confronting, and expensive one.
With the Australian medical cannabis landscape evolving, it’s hard for patients to keep tabs on the most current information around coverage, rebates and government support for their care. With limited access to financial support, the decision for patients to explore medical cannabis has been a confronting, and expensive one.
Heading into 2023, patients are now looking at more financial support and access than ever before.
Here we’ll break down some of the complexities and offer simplified answers around medical cannabis coverage, Medicare rebates, the PBS, and how Private Health Insurance can help connect the dots.
Here are the foundations to start with:
Laws vary from state-to-state and often change, so this is a snapshot of the current climate: sourced from Health Victoria as of March, 2022.
Victoria: Any doctor in Victoria can prescribe medical cannabis for any patient with any condition if they have the required Commonwealth and/or State approvals.
New South Wales: In NSW any doctor can legally prescribe medicinal cannabinoids for a health condition if they believe it is an appropriate treatment option for their patient, and they have obtained the relevant authorities from the Therapeutic Goods Administration (TGA). Approval will be based on the severity of your condition and the type of medical condition it will be treating.
Queensland: Any registered medical practitioner in Queensland can prescribe medical cannabis for any patient with any condition if they believe it is clinically appropriate and has obtained the required Commonwealth approval.
South Australia: Medical practitioners can legally prescribe medical cannabis products subject to both Commonwealth and State regulatory requirements.
Tasmania: Accessing medical cannabis prescriptions in Tasmania is slightly different from the rest of the country. Your local GP cannot prescribe your medical cannabis directly, so you must be referred by your medical practitioner to a specialist doctor. In Tasmania, medical cannabis applications are approved based on the patient’s condition, medical history, and proof they have adequately trialled other avenues of conventional treatments. For TGA approval, the application must provide some scientific evidence substantiating the medical cannabis prescription for your condition or symptoms.
Western Australia: Any doctor in Western Australia can prescribe medical cannabis if they believe the treatment is appropriate.
Australian Capital Territory: In the ACT, prescribers must have approval from the ACT Chief Health Officer and from the TGA to prescribe medical cannabis.
Northern Territory: A patient living in the Northern Territory must access medicines containing cannabinoids through an Australian doctor who is authorised under the Special Access or Authorised Prescriber Scheme administered by the Therapeutic Goods Administration.
First, we always recommend confirming your coverage before booking your appointment or submitting claims.
With a general lack of understanding through customer service teams, be patient and know that you may need to do some digging to get to the right people. When you DO access the right information, get confirmation of your coverage in writing directly from the insurer so there is no confusion in the case that you are reading conflicting information.
With access to an increasing medical coverage, making a claim is often easy to navigate. Again, be sure to confirm with your insurer about your coverage first, and know exactly what you will need in order to make a claim. Always review your policy and ask questions first.
As we mentioned, patients will typically need proof of TGA approval, a letter from the Doctor and a non-PBS payment receipt in order to make a claim. Patients should know that they will most likely pay for medication upfront, and then submit the claim directly to the insurer to receive reimbursement.
Non-PBS pharmacy annual limits may be shared with other extras benefits in your policy.
The plans listed are the lowest cost plans and therefore the lowest benefits.
The extras and benefits listed are per-person, not a family rate.
*Medical cannabis scripts covered at the health fund’s discretion.
**E = extras only plans available
H + E = can only get extras with hospital plan
Looking into 2023, here is an outline of medical cannabis coverage in Australia:
Does Medicare Cover Medical Cannabis Appointments
Medicare often provides rebates for in-person GP visits that are billed under MBS item numbers.
So typically, if you are visiting your GP, who is also your medical cannabis prescriber, and you are billed for just your visit then likely YES, Medicare will offer its standard rebate for your medical cannabis appointment.
Unfortunately, Telehealth appointments offer minimal to no coverage and are an exception to the rule.
Does the PBS cover my medical cannabis or CBD oil?
The PBS only covers ARTG (Australian Register of Therapeutic Goods) listed medications,
Because medicinal cannabinoids remain largely unapproved, it is not covered by the PBS. There are two medical cannabinoid products (Sativex + Epidiolex) that currently ARE listed, but remain uncovered.
Does private insurance pay for medical cannabis or CBD oil?
Somewhere around 81% of private Australian health insurers offer some form of coverage under the SAS (Special Access Scheme) or AP (Authorised Prescriber) pathways. Of these insurers, most said that the product must be prescribed through these pathways and compounded medications would not be reimbursed.
Primarily, your private insurer will offer some coverage for all medical cannabis products so long as the following documentation is provided:
Proof of TGA approval (provided by your prescriber)
A letter from the prescribing doctor (a template may be provided by insurer)
A specific receipt (available on request and different to a tax receipt) proving your medication is not covered by the PBS
Most private insurers will cover some, or all of the costs of medicinal cannabis prescriptions, offering coverage under their General Treatment or Extras plans for non-PBS prescriptions (like Medical Cannabis).
The Cost of Medication with Coverage
All insurers that offer cover for medical cannabis require the patient to pay the PBS co-payment up front before the insurer will begin coverage. In 2022, the maximum PBS co-payment was $42.50. Following the co-payment insurers will cover a stipulated % or $ towards the script, covering some or all depending on your policy.
With an Extras plan that includes medical cannabis, patients will cover a portion of their script fee with the insurer covering all or some of the remaining balance. All private plants offer different coverage, but will have a predetermined maximum cost per year.
What Canna-Medications Are Approved in Australia?
Currently in Australia there are two ATGA approved medications, Sativex and Epidyolex.
In addition, Authorised Prescribers are able to prescribe unapproved products that have TGA (the Commonwealth Therapeutic Goods Administration) approval for use.
A list of unapproved medicinal cannabis products has been published on the TGA website.
Treatment using medical cannabis is unique to each patient and the cost will vary depending on the dosing and prescribed product, which is determined through consultation with your GP and may impact what level of coverage patients have.
Typically medical cannabis is covered under non-PBS pharmaceuticals category with most private funds.
Regardless if your prescription is ARTG approved, the TGA must approve your prescription through the SAS or AP programs. You will be denied approval if you are prescribed a compounded product.
When speaking to your insurer, patients can ask if S4 or S8 prescriptions approved by the TGA through SAS or AP programs are covered. Inquiring specifically about Cannabidiol or CBD may also be helpful.
DISCLAIMER: The Ananda Clinics blog is here to provide education and information, without implying medical advice, or recommendation for the use of cannabis as medicine or adult use purposes.
Medical cannabis remains strictly regulated by the Australian TGA as it is not a registered therapeutic agent due to the lack of research and evidence in support of its efficacy or potential side effects.
If you think medical cannabis may be right for you, book an appointment with one of our doctors to find out more.
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