Pharmaceutical co-payments

All prescriptions from a public hospital, a midwife and a Family Planning Clinic are covered for $5 prescription co-payments.

Prescriptions from the following providers are approved for $5 prescription co-payments on subsidised medicines.

• Public hospital
• A midwife
• Family Planning Clinic
• Your GP (as long as they are part of a PHO)
• After Hours Accident and Medical Services (as long as they have a DHB or a PHO contract)
• Youth Health Clinics (as long as they have a DHB or a PHO contract)
• Dentists (only if the prescription relates to a service being provided under a DHB contract)
• Private specialists (only if the prescription relates to a service being provided under a DHB contract)
• Hospices (as long as they have a DHB contract)
• ACC-related claim

There is no prescription co-payment on these medicines for children aged 14 and under.

Hospitals have a list of eligible providers in their respective regions. Any provider/prescriber not specifically listed as an approved provider/prescriber should be regarded as not approved.

Once patients and their families have collected 20 prescription items in a year, they can get a Prescription Subsidy card, which means they won’t have to pay any more prescription charges until 1 February the following year. 

If the prescription is not coded the pharmacist needs to confirm that the:

• patient is eligible for publicly funded pharmaceuticals
• prescriber is approved for prescription co-payments.

When the pharmacist has established whether the patient is eligible and whether the prescriber is an approved prescriber the pharmacist can decide what the correct code is for prescription co-payment purposes.

However, the pharmacist must have information which they can point to and which they believe is factual that indicates that the prescription is issued by an approved prescriber for an eligible person.

Examples include:

• a Te Whatu Ora list of approved providers
• that the prescription is written on a public hospital prescription pad
• advice from Te Whatu Ora that the prescriber is approved (such as midwives and family planning clinics).

The alteration to the coding on the prescription should be done in a manner that is identifiable and auditable, as required in the Pharmacy Procedures Manual v 8.0 at clause 6.13 for annotations.

The pharmacist can determine a patient’s eligibility for publicly funded pharmaceuticals by:

• checking with the prescriber or
• verifying eligibility directly with the patient.

The pharmacist is entitled to rely on the prescriber’s information about the patient’s eligibility.

A patient may directly provide proof of eligibility by proving that they are a New Zealand citizen or having the correct permits in their passport.

Without exception all prescriptions for fully subsidised medicines for patients eligible for publicly funded services that are obtained from a public hospital prescriber, a midwife and/or a Family Planning Clinic prescriber are approved for $5 prescription co-payments.

In the case of other prescribers/providers, the pharmacist can either check with the prescriber or rely on Te Whatu Ora' s information about approved and non-approved providers/prescribers.

The following providers are approved if they meet the specified criteria.

• After-hours providers with an access or service agreement with an approved service provider. Te Whatu Ora can provide pharmacists with a list of approved after-hours providers.
• Youth health clinics are approved if the clinic has a Te Whatu Ora contract for services.
• Dentists are approved if the prescription relates to a service being provided under a Te Whatu Ora contract.
• Private specialists (eg, ophthalmology, orthopaedics) are approved if the prescription relates to a patient receiving a publicly funded service contracted by Te Whatu Ora.
• During normal business hours (ie, not after hours) general practitioners where the person is not enrolled (ie, ‘casual’ visits) are approved if the person is an eligible person and the general practice is part of a PHO.
• Hospices are approved if they have a contract with Te Whatu Ora.

Any provider/prescriber not specifically listed by Te Whatu Ora as an approved provider/prescriber should be treated as not approved.

The following list specifies the circumstances under which a prescriber/provider is not approved for $5 prescription co-payments on publicly funded pharmaceuticals. Te Whatu Ora may also provide a list of the general practitioners in their district who are not approved.

• General practitioners who are not part of a PHO are not approved unless they have other service agreements with Te Whatu Ora for publicly funded services.
• Private specialists are not approved if the prescription does not relate to a patient receiving a publicly funded service contracted by Te Whatu Ora and is issued in the course of their private practice and relates to a private patient receiving a privately funded service.
• Providers/prescribers providing a service that is privately funded and do not have a contract with Te Whatu Ora are not approved.

When the pharmacist has established whether the person is eligible and whether the prescriber can prescribe publicly funded pharmaceuticals, the pharmacist can decide what the correct code is for prescription co-payment purposes.

If a prescription for an eligible person is not coded for the correct co-payment, the pharmacist can complete the missing factual information. This should be done in a manner that is identifiable and auditable, as required in the Pharmacy Procedures Manual v 8.0 at clause 6.13 for annotations.

Where a patient is eligible for publicly funded medicines and the prescriber is approved for $5 prescription co-payments on subsidised medicines and the pharmacist has information that indicates the prescription is coded incorrectly, the pharmacist may alter the code.

However, the pharmacist must have information which they can point to and which they believe is factual. Examples include:

• a list of approved providers
• that the prescription is written on a public hospital prescription
• advice from the Ministry that the prescriber is approved (such as midwives and family planning).

The alteration to the coding on the prescription should be done in a manner that is identifiable and auditable, as required in the Pharmacy Procedures Manual v 8.0 at clause 6.13 for annotations.

If the medical condition meets the necessary requirements and the patient meets the necessary eligibility conditions then the patient will be eligible for a pharmaceutical subsidy. Although the tourist cannot join a PHO, if the prescriber is an approved provider/prescriber the $5 prescription co-payment will apply.

An Australian citizen or Australian permanent resident on a temporary visit to New Zealand, who requires medical treatment that is immediately and clinically necessary for the diagnosis, alleviation or care of that condition, will be entitled to subsidised pharmaceuticals in relation to that condition only.

A UK citizen, temporarily in New Zealand, who requires prompt medical treatment for a condition arising after they arrived in New Zealand (or became acutely exacerbated after arrival), will be entitled to subsidised pharmaceuticals in relation to that condition only.

ACC prescriptions are funded by ACC, but ACC advise that all ACC-related prescriptions should be coded A4 for a $5 prescription co-payment.

For medical-related prescriptions, as opposed to accident-related ones, the after-hours provider would have to have a hospital or a PHO contract.