A total of 26 billing codes in Part D (for medicines and accessories to medicines) will be removed from the Prescribed List effective 1 November 2024.
These 26 billing codes are regulated by the Therapeutics Goods Administration as medicines or accessories to medicines and therefore do not meet the Prescribed List eligibility requirements.
We have considered stakeholder feedback regarding the clinical value of these items. The private health insurance sector has also acknowledged these products have clear clinical value and are keen to see continued access for insured patients. Therefore, we encourage all parties to work together to find a way to fund these medicines and accessories to medicines to ensure there is minimum disruption to their availability for clinicians and patients.
We would like to remind stakeholders that private health insurers are required to pay benefits in accordance with the billing code listed for that device or product if it meets the following requirements:
- the patient receives the product as part of hospital treatment or hospital substitute treatment
- the patient has appropriate health insurance to cover for the treatment
- a Medicare benefit is payable for a service associated with the use of the device or product.
This includes devices or products undergoing a post-listing review; being reviewed for incorrect listing; or that are expected to come off the Prescribed List in the future.
Therefore, private health insurers are required to pay benefits for any medicine or medicine accessories that are used in procedures up until 1 November 2024.