View Full Version : Health Fund Coverage on Concerta


standtall
02-20-12, 02:09 AM
BUPA/MBF has rejected my claim for Concerta reimbursement on the grounds that Concerta is listed on PBS. However, it is listed for patients with ages up to 18 years and as far as Adults are concerned, there is no PBS coverage.

I have complained to them but they are hiding behind the wording and saying as long as it is listing on PBS, they are NOT going to provide a benefit regardless of whether PBS listing is applicable on me or not.

Did anyone have any luck with getting Concerta reimbursed by these greedy health funds? I don't know why I am paying $200 a month when they have rejected my only claim in last 5 years on flimsy grounds??

emploding
02-20-12, 05:09 PM
Seriously? That's flawed logic if I ever heard it!

Did you call and talk to them about it? I'd be disputing that, big time. Maybe call as a "I'm looking to join your health fund and want to know if this and this is covered" because you often get different answers that way.

MissesS
02-20-12, 05:14 PM
I haven't had this problem as i dont take concerta but I do sympathise with you.
(had a recent issue with my private health fund too which I complained about.) I have had problems with them not covering non PBS medication but I did not challenge it. They did print me a letter with a long list of conditions why they don't pay for some non PBS medications - I remember being surprised as I thought not being on the PBS and having to pay full price was the only reason!

You should persue it with them. I would be even more determined to do so since you pay a substantial monthly premium and havent claimed in 5 years!

Good luck!

standtall
02-20-12, 06:38 PM
I haven't had this problem as i dont take concerta but I do sympathise with you.
(had a recent issue with my private health fund too which I complained about.) I have had problems with them not covering non PBS medication but I did not challenge it. They did print me a letter with a long list of conditions why they don't pay for some non PBS medications - I remember being surprised as I thought not being on the PBS and having to pay full price was the only reason!

You should persue it with them. I would be even more determined to do so since you pay a substantial monthly premium and havent claimed in 5 years!

Good luck!

Exactly - I have reported this to Health Fund Ombudsman. It is an issue with MBF/BUPA's value system. Ombudsman phone lady told me that MBF generates lots more complaints than their market share and I am not surprised.

I have cancelled my MBF cover and have moved to cheapest cover with Medibank that doesn't have pharma cover but I am paying $70 less which means I don't care if medicine is not covered.

By their greed and dishonesty, MBF have lost a profitable customer (I was paying $2000 a year without claiming anything back) and will pay a few hundreds to pursue this with Ombudsman and eventually end up paying those very 60 bucks they were trying to cheat away from a customer.

If you are with MBF/BUPA, don't have any illusions that your cover will actually work for you. When you will claim, they will find a way to hide behind something and reject your claim.

emploding
02-20-12, 07:09 PM
If you are with MBF/BUPA, don't have any illusions that your cover will actually work for you. When you will claim, they will find a way to hide behind something and reject your claim.

I left MBF not long after they were taken over by BUPA and am now in an industry fund. Will be interesting to see if they pay my claim for ritalin when later this week, it didn't occur to me that they might not!

MissesS
02-20-12, 09:01 PM
I left MBF not long after they were taken over by BUPA and am now in an industry fund. Will be interesting to see if they pay my claim for ritalin when later this week, it didn't occur to me that they might not!

Is Ritalin not covered? I was originally prescribed this to treat my ADHD and I couldn't believe how cheap it was when I paid the chemist

standtall
02-21-12, 06:20 AM
Is Ritalin not covered? I was originally prescribed this to treat my ADHD and I couldn't believe how cheap it was when I paid the chemist

Ritalin is not covered but it is on PBS hence it is so cheap. Concerta is only on PBS for kids and not for adults hence it should be covered.

Driver
02-21-12, 06:34 AM
Even though I have health insurance, I don't take Concerta because at the cost per month it'd cost me, I wouldn't be able to find a health fund with enough pharma cover to make the costs bearable.

MissesS
02-21-12, 08:33 AM
Ritalin is not covered but it is on PBS hence it is so cheap. Concerta is only on PBS for kids and not for adults hence it should be covered.

Sorry I meant not on PBS. As I understood, emploding was going to make a claim for Ritalin to her private health fund. I questioned it because I thought if Ritalin is on the PBS, it does not qualify for a claim.

Just out of curiosity, how much is Concerta?

My dr gave me a prescription for zyban which he wrote as a "private script". Chemist said I would have to pay full because of this. He did say my private health fund would pay - Im beginning to think they probably won't probably citing that because it is on the PBS (conditionally)

I claimed for my melatonin today and got <$20 back, out of pocket about $30. A tip - I did discover not buy the melatonin that the chemist stocks behind the counter. To fulfil my script with this brand, it was going to cost me over $130! A compound chemist made up the same script for $55!

MissesS
02-21-12, 08:43 AM
Exactly - I have reported this to Health Fund Ombudsman. It is an issue with MBF/BUPA's value system. Ombudsman phone lady told me that MBF generates lots more complaints than their market share and I am not surprised.

I have cancelled my MBF cover and have moved to cheapest cover with Medibank that doesn't have pharma cover but I am paying $70 less which means I don't care if medicine is not covered.

By their greed and dishonesty, MBF have lost a profitable customer (I was paying $2000 a year without claiming anything back) and will pay a few hundreds to pursue this with Ombudsman and eventually end up paying those very 60 bucks they were trying to cheat away from a customer.

If you are with MBF/BUPA, don't have any illusions that your cover will actually work for you. When you will claim, they will find a way to hide behind something and reject your claim.

Good on you for contacting the ombudsman!
Interesting to note that MBF seems to have a reputation.
My fund is with HCF. I complained about their dodgy practices in their Dental Centres when they treat children. They did reverse the items and the head dentist offered to perform another check up but I've decided I'm done going there and will only visit private clinics from now on.

I'm going to need to re-evaluate private health insurance with this recently announced cuts to the rebate. :faint:

emploding
02-21-12, 11:24 PM
Sorry I meant not on PBS. As I understood, emploding was going to make a claim for Ritalin to her private health fund. I questioned it because I thought if Ritalin is on the PBS, it does not qualify for a claim.


Sorry for confusing you, I didn't realise Ritalin was on the PBS, I thought it was on only for kids like Concerta.

My Ritalin last night was $22 for 100 tablets (just started it today).

standtall
02-23-12, 09:47 PM
I have discovered the issue in further detail.

1) First of all, it is somewhat discriminatory for Department of Health & Ageing to deny Concerta benefit to consumers based on their age. They are essentially saying Adult ADHD is not debilitating enough.

2) Secondly, they even encourage Private Health Funds not to bother providing benefit to those full price paying consumers by telling Health Funds that they don't have to provide benefits for PBS listed drugs. If they had bothered to stress on the fact that a mere PBS listing doesn't mean PBS coverage, Health funds would have been forced to cover Concerta. It is a shame that you will be subsidized for a boob job if you have the cover but not for your ADHD medication!!!

In summary, you are paying $80 a month because your incompetent government is discriminating you on your age. Before PBS listing, everybody was getting subsidized by health funds - Now you are neither being subsidized by PBS nor by health funds.

If you live in Australia, please raise your concern to Health Minister. This can be done via an email and if they receive a few emails, they might realize their stupidity.

Email address is : Minister.Plibersek@health.gov.au.

Please include your Full Name and address in your email to Health Minister to receive a reply.

If you care about ADHD and your rights as an ADHD survivor, please take 5 minutes to write this email. It might change things for better for so many of ADHD sufferer who already have too much discrimination to overcome based on their condition.

Thanks

MissesS
02-25-12, 11:46 PM
http://pbs.gov.au/info/publication/factsheets/professional/2009-10-01-Updates_1_October_2009

This is interesting...Initially it was restricted to those under 18 but in October 2009 it changed.

Concerta is available on the PBS to those over 18 if they were diagnosed with ADHD between the ages of 6 to 18. This is also the case with Strattera.

They have recognised that once these children become adults, treatment needs to continue BUT it's discrimination against those diagnosed as an adults :mad:

Does anyone know how this is enforced? As an adult with a Concerta prescription, how do they know when I was diagnosed and thereby know how much to charge me for the prescription?

Driver
02-25-12, 11:52 PM
http://pbs.gov.au/info/publication/factsheets/professional/2009-10-01-Updates_1_October_2009

This is interesting...Initially it was restricted to those under 18 but in October 2009 it changed.

Concerta is available on the PBS to those over 18 if they were diagnosed with ADHD between the ages of 6 to 18. This is also the case with Strattera.

They have recognised that once these children become adults, treatment needs to continue BUT it's discrimination against those diagnosed as an adults :mad:

Does anyone know how this is enforced? As an adult with a Concerta prescription, how do they know when I was diagnosed and thereby know how much to charge me for the prescription?

1. Medicare have a record of all PBS meds you've taken.
2. If a doc prescribes you medicine you're not allowed to have, they'll get in trouble.

MissesS
02-26-12, 12:44 AM
1. Medicare have a record of all PBS meds you've taken.
2. If a doc prescribes you medicine you're not allowed to have, they'll get in trouble.

Thanks Driver. Is that what the pharmacist checks while I wait for medication? Always wondered why it took so long for them to reach out to a shelf for a box and print up a label!

Driver
02-26-12, 01:46 AM
Thanks Driver. Is that what the pharmacist checks while I wait for medication? Always wondered why it took so long for them to reach out to a shelf for a box and print up a label!

It's what the doctor does when he calls up the PBS to get authorisation to prescribe your medication.

MissesS
02-26-12, 02:42 AM
How does the pharmacist know what to charge then?

If you have been on Concerta since you were a child/teen and now as an adult, you are getting it on the PBS.

Or if you are an adult who has recently being diagnosed and has been prescribed Concerta but you're not eligible for the PBS subsidy because your diagnosis did not occur when you were aged between 6-18.

Driver
02-26-12, 02:44 AM
How does the pharmacist know what to charge then?

If you have been on Concerta since you were a child/teen and now as an adult, you are getting it on the PBS.

Or if you are an adult who has recently being diagnosed and has been prescribed Concerta but you're not eligible for the PBS subsidy because your diagnosis did not occur when you were aged between 6-18.

You'll either have a PBS script or a private script.

standtall
02-27-12, 06:23 PM
How does the pharmacist know what to charge then?

If you have been on Concerta since you were a child/teen and now as an adult, you are getting it on the PBS.

Or if you are an adult who has recently being diagnosed and has been prescribed Concerta but you're not eligible for the PBS subsidy because your diagnosis did not occur when you were aged between 6-18.

I called PBS to ask the logic behind this stupid rule and they have no answer. Apparently some committee meets once in some couple of years to make these decisions.

Initially, Concerta was on PBS for patients under 18 years and when some of them grew 18, they protested against lack of subsidy after 18 and PBS changed the rule to include them as well but not thinking about those who were going to be diagnosed after age 18.

This is the height of incompetence in our medical system and they would only do something if you put them on the spot.

Please make sure you send an email to Health Minister to get this fixed.

MissesS
02-28-12, 12:04 AM
I called PBS to ask the logic behind this stupid rule and they have no answer. Apparently some committee meets once in some couple of years to make these decisions.

Initially, Concerta was on PBS for patients under 18 years and when some of them grew 18, they protested against lack of subsidy after 18 and PBS changed the rule to include them as well but not thinking about those who were going to be diagnosed after age 18.

This is the height of incompetence in our medical system and they would only do something if you put them on the spot.

Please make sure you send an email to Health Minister to get this fixed.

Yep, you are right - it is stupid! I will be writing an email.

We have little choice of meds available in Australia as it is. And what is available, most arent subsidized.

Correct me if I'm wrong, but is it only dex and Ritalin that is on the PBS for adults?

emploding
02-28-12, 12:38 AM
Correct me if I'm wrong, but is it only dex and Ritalin that is on the PBS for adults?

Yes, as far as I'm aware. We don't even have half the meds they have in other parts of the world :/

I wonder how the PBS thing for Concerta is worded. I was diagnosed with ADD when I was 7 but my parents didn't believe it or accept it so it was ignored and I was never medicated or treated. But I was diagnosed!

Then again, anyone could say they were diagnosed 20+ years ago, doubt their are many medical records still around from then. I wonder if it's only a matter of a doctor ticking the box to allow you to access Concerta on the PBS. If so, try telling them you were recently discussing your adult ADHD diagnoses with your parents and they said "but you were diagnosed with that as a kid!" and see what the doc says ;)

MissesS
02-28-12, 07:28 AM
http://pbs.gov.au/info/publication/factsheets/professional/2009-10-01-Updates_1_October_2009



Heres a link that has some wording around it. If you google PBS and Concerta you'll find a couple more from the PBS website. From memory, I think Concerta was first available on the PBS in 2007 (for children)

Driver
02-28-12, 07:36 AM
Yes, as far as I'm aware. We don't even have half the meds they have in other parts of the world :/


Yup, did a search on the ARTG and didn't find Adderall, Vyvanse etc. So we can't even get them on a private script.

Pansie
02-29-12, 12:09 AM
Sadly as adults we are only eligible to use short-acting stimulants under the PBS.

I don't know how much the Concerta costs, but I get Dex turned into a long-acting capsule at the Compounding Pharmacist, that is about $80 + prescription price. My boys did best on Dex and since for some unknown reason Aust doesn't have a XR version I have to get them compounded. Fortunately the $80 compounding fee covers 1 - 2 prescriptions so it covers both my boys. I don't know how the health funds look at compounding but it could be something to look into.

Pansie
02-29-12, 12:13 AM
It could be under $80, I'm having a blank. Prices can vary widely between pharmacies too.

MissesS
02-29-12, 01:20 AM
Sadly as adults we are only eligible to use short-acting stimulants under the PBS.

I don't know how much the Concerta costs, but I get Dex turned into a long-acting capsule at the Compounding Pharmacist, that is about $80 + prescription price. My boys did best on Dex and since for some unknown reason Aust doesn't have a XR version I have to get them compounded. Fortunately the $80 compounding fee covers 1 - 2 prescriptions so it covers both my boys. I don't know how the health funds look at compounding but it could be something to look into.

I know the receipts printed have the medication details on there. I know my health insurer won't pay in this situation because it's dex is on the PBS.

What you are doing is a good idea. I have heard that dex made from a compounding is better. Can you rock up to any compounding chemist and do this?

Pansie
02-29-12, 01:47 AM
I know the receipts printed have the medication details on there. I know my health insurer won't pay in this situation because it's dex is on the PBS.

What you are doing is a good idea. I have heard that dex made from a compounding is better. Can you rock up to any compounding chemist and do this?

You have to get a letter from your doctor to take to the chemist asking for it to be prepared into a long acting 12 hour (i think) dose. If you find a chemist who will do it at a price you're happy with first, you can ask them if they need any specific information and make sure that's covered in the doctor's note.