Southern Cross vs nib — Health Insurance

KiwiCare

Chemotherapy for cancer (base) covers Pharmac approved chemotherapy drugs and up to $8,000 each claims year for chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated for treatment of the cancer diagnosed. Cancer Cover Plus upgrades (Chemotherapy 100 and Chemotherapy 300) cover both Pharmac approved and non-Pharmac approved but Medsafe-indicated chemotherapy drugs with no separate sub-limit for non-Pharmac drugs, up to the respective annual limit. IV infusions (non-cancer) do not cover the cost of drugs that are not Pharmac approved. Allergy services do not cover the cost of drugs that are not Pharmac approved. RegularCare prescriptions exclude cover for drugs that are not Pharmac approved.

Source PDF · 2026-04-01

RegularCare

Generally, drugs must be Pharmac approved to be covered. Under the 'Chemotherapy for cancer (base)' benefit, up to $8,000 each claims year is available for chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated for treatment of the diagnosed cancer; the Cancer Cover Plus upgrades (Chemotherapy 100 and Chemotherapy 300) cover non-Pharmac-approved but Medsafe-indicated chemotherapy drugs without a stated sub-limit (subject to the overall annual cap). The 'IV infusions (non-cancer)' benefit covers IV infusions of Medsafe-indicated drugs but does not cover the cost of drugs that are not Pharmac approved. The 'Day-to-day treatment' prescriptions benefit excludes cover for drugs that are not Pharmac approved. If drugs would require special authority from Pharmac in a public facility, they are only covered if the same special authority criteria are met.

Source PDF · 2026-04-01

UltraCare

Under the Chemotherapy for cancer (base) benefit: Pharmac approved chemotherapy drugs are covered within the $60,000 annual limit; chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated for treatment of the diagnosed cancer are covered up to $10,000 each claims year (included within the $60,000 limit). Under Cancer Cover Plus upgrades (Chemotherapy 100 and Chemotherapy 300): both Pharmac approved and non-Pharmac approved but Medsafe-indicated chemotherapy drugs are covered without a separate sub-limit, up to $100,000 or $300,000 each claims year respectively. Under the IV infusions (non-cancer) benefit: drugs that are not Pharmac approved are not covered. Under the Day-to-day treatment prescriptions benefit: drugs that are not Pharmac approved are excluded. Under Allergy services: drugs that are not Pharmac approved are not covered.

Source PDF · 2026-04-01

Wellbeing Modules

Prescriptions cover excludes cover for drugs that are not Pharmac approved

Source PDF · 2026-04-01

Wellbeing One

Chemotherapy for cancer (base) covers Pharmac approved chemotherapy drugs and up to $10,000 each claims year for chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated for treatment of the cancer diagnosed. Under the Cancer Cover Plus upgrades (Chemotherapy 100 or Chemotherapy 300), chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated are covered without a separate sub-limit, subject to the overall annual cap ($100,000 or $300,000). The IV infusions (non-cancer) benefit does not cover the cost of drugs that are not Pharmac approved. The Allergy services benefit does not cover the cost of drugs that are not Pharmac approved. The Keeping Well Module and Day-to-day Module prescription benefits exclude cover for drugs that are not Pharmac approved.

Source PDF · 2026-04-01

Wellbeing Two

Pharmac approved chemotherapy drugs are covered under the Chemotherapy for cancer (base) benefit ($60,000 each claims year). Non-Pharmac approved but Medsafe-indicated chemotherapy drugs are covered up to $10,000 each claims year within that $60,000 limit under the base benefit. Under Cancer Cover Plus upgrades (Chemotherapy 100 or Chemotherapy 300), chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated are covered up to the upgraded annual limit ($100,000 or $300,000) with no separate sub-limit for non-Pharmac drugs. IV infusions (non-cancer) do not cover the cost of drugs that are not Pharmac approved. Allergy services do not cover the cost of drugs that are not Pharmac approved. Optional modules (Keeping Well and Day-to-day) exclude cover for drugs that are not Pharmac approved.

Source PDF · 2026-04-01

KiwiCare

The KiwiCare and RegularCare plans do not provide cover for healthcare services related to acute care or to an accident, treatment injury or work-related gradual process injury that ACC is legally responsible for. If ACC does not pay the full amount charged, you may claim the shortfall under the relevant benefit via the 'Accident and treatment injury top-up' benefit — up to 80% of the remaining cost after the ACC contribution has been deducted, subject to the policy limits for the relevant benefit. You must do everything reasonably possible to obtain ACC approval for payment, including signing all documents to enable Southern Cross to protect any ACC entitlement.

Source PDF · 2026-04-01

RegularCare

The plans do not provide cover for healthcare services related to acute care or to an accident, treatment injury, or work-related gradual process injury that ACC is legally responsible for. However, if ACC does not pay the full amount charged, the member may claim the shortfall under the 'Accident and treatment injury top-up' benefit — the policy covers up to 80% of the remaining eligible cost after the ACC contribution has been deducted, up to the policy limits for the relevant benefit. Members must do everything reasonably possible to obtain ACC approval before claiming the top-up, including signing all documents to enable Southern Cross to protect any entitlement from ACC.

Source PDF · 2026-04-01

UltraCare

The UltraCare plans do not cover healthcare services related to acute care or to an accident, treatment injury, or work-related gradual process injury that ACC is legally responsible for. However, if ACC does not pay the full amount charged for treatment, the policyholder can claim the shortfall under the relevant benefit via the 'Accident and treatment injury top-up' benefit, subject to that benefit's policy limits and terms. The insured must do everything reasonably possible to obtain ACC approval for payment, including signing all necessary documents, and must co-operate to enable Southern Cross to protect any ACC entitlement.

Source PDF · 2026-04-01

Wellbeing Modules

Not on file.

Source PDF · 2026-04-01

Wellbeing One

The Wellbeing plans do not provide cover for healthcare services related to an accident, treatment injury, or work-related gradual process injury that ACC is legally responsible for. Where ACC does not pay the full amount charged, the insured may claim the shortfall under the 'Accident and treatment injury top-up' benefit, subject to the policy limits and conditions of the relevant benefit. The insured must do everything reasonably possible to obtain ACC approval for payment, including signing all necessary documents to enable Southern Cross to protect any ACC entitlement.

Source PDF · 2026-04-01

Wellbeing Two

The Wellbeing plans do not provide cover for healthcare services related to acute care or to an accident, treatment injury or work-related gradual process injury that ACC is legally responsible for. If ACC does not pay the full amount charged for treatment, the member can make a claim for the shortfall under the relevant benefit if that healthcare service is covered under the policy — this is the 'Accident and treatment injury top-up' benefit. The member must do everything reasonably possible to obtain ACC approval for payment, including signing all documents and doing everything necessary to enable Southern Cross to protect any entitlement from ACC. Southern Cross will cover the remaining cost of the eligible healthcare service after the ACC contribution has been deducted, up to the policy limits for the relevant benefit.

Source PDF · 2026-04-01

KiwiCare

MH sublimit: $2,250

Psychiatric hospitalisation benefit provides cover for admission and care by a specialist who is vocationally registered in psychiatry in an approved facility. We'll cover 80% of the actual charges incurred for psychiatric admission and care, to a maximum of $2,250 each claims year. Sub-limits apply: up to $450 for each night or day-stay in hospital accommodation; up to $160 each claims year for ancillary hospital charges. No excess applies to this benefit. Psychiatrist consultations are covered separately up to $600 each claims year at 80% of actual charges.

Source PDF · 2026-04-01

RegularCare

MH sublimit: $2,250

Cover for psychiatric hospitalisation is $2,250 each claims year. This covers admission and care by a specialist who is vocationally registered in psychiatry in an approved facility. Sub-limits apply: up to $450 for each night or day-stay in hospital accommodation, and up to $160 each claims year for ancillary hospital charges. No excess applies to this benefit. Mental health healthcare services are otherwise excluded except for psychiatrist consultations ($600 each claims year) and, for RegularCare plan holders, the Day-to-day treatment benefit.

Source PDF · 2026-04-01

UltraCare

MH sublimit: $1,500

Psychiatric hospitalisation is covered up to $3,500 each claims year. This requires admission and care by a specialist who is vocationally registered in psychiatry in an approved facility. Sub-limits apply: up to $700 for each night or day-stay in hospital accommodation; up to $200 each claims year for ancillary hospital charges. Reasonable charges apply. Mental health consultations (with a psychiatrist vocationally registered in psychiatry, or a psychologist registered with the New Zealand Psychologists Board) are covered up to $1,500 each claims year. General mental health costs are otherwise excluded except as covered under the Mental health consultations benefit, Psychiatric hospitalisation benefit, and Day-to-day treatment benefit.

Source PDF · 2026-04-01

Wellbeing Modules

Not on file.

Source PDF · 2026-04-01

Wellbeing One

MH sublimit: $3,500

Psychiatric hospitalisation is covered up to $3,500 each claims year for admission and care by a specialist who is vocationally registered in psychiatry in an approved facility. Sub-limits apply: up to $700 for each night or day-stay in hospital accommodation, and up to $200 each claims year for ancillary hospital charges. Reasonable charges are covered. No excess applies to this benefit. Psychiatrist consultations are covered separately up to $750 each claims year (reasonable charges, no excess).

Source PDF · 2026-04-01

Wellbeing Two

MH sublimit: $3,500

The 'Psychiatric hospitalisation' benefit provides cover for admission and care by a specialist who is vocationally registered in psychiatry in an approved facility. Cover is up to $3,500 each claims year, including sub-limits of up to $700 for each night or day-stay in hospital accommodation and up to $200 each claims year for ancillary hospital charges. We'll cover the reasonable charges incurred. No excess applies to this benefit. Psychiatrist consultations (outpatient) are covered under a separate benefit up to $750 each claims year.

Source PDF · 2026-04-01

KiwiCare

We don't cover any costs related to, or incurred as a consequence of, any pre-existing conditions unless we've clearly stated otherwise on your membership certificate. This exclusion doesn't apply to cover provided under the 'Day-to-day treatment' benefit if you have the RegularCare plan. Pre-existing conditions that the policyholder has made us aware of are listed on the membership certificate.

Source PDF · 2026-04-01

RegularCare

The policy does not cover any costs related to, or incurred as a consequence of, any pre-existing conditions unless clearly stated otherwise on the membership certificate. This exclusion does not apply to cover provided under the 'Day-to-day treatment' benefit for RegularCare plan holders. The policyholder must disclose any health conditions, signs, symptoms on application. Pre-existing conditions may be noted on the membership certificate.

Source PDF · 2026-04-01

UltraCare

Pre-existing conditions are excluded unless clearly stated otherwise on the membership certificate. This exclusion does not apply after 3 years of continuous cover on this plan, and does not apply to cover under the 'Day-to-day treatment' benefit or the 'Vision and Dental' benefit (UltraCare 400 plan). Pre-existing conditions disclosed by the policyholder are listed on the membership certificate. If information on the membership certificate contradicts this policy document, the membership certificate takes precedence.

Source PDF · 2026-04-01

Wellbeing Modules

Not on file.

Source PDF · 2026-04-01

Wellbeing One

Pre-existing conditions are excluded unless clearly stated otherwise on the membership certificate. This exclusion does not apply to cover provided under the optional modules. The prophylactic treatment allowance is not available if the person was confirmed as having a high risk of developing the disease the prophylactic treatment is designed to prevent before their original date of joining, unless the membership certificate specifically states otherwise.

Source PDF · 2026-04-01

Wellbeing Two

We don't cover any costs related to, or incurred as a consequence of, any pre-existing conditions unless we've clearly stated otherwise on your membership certificate. This exclusion doesn't apply to cover provided under the optional modules. Pre-existing conditions that the policyholder has made us aware of are listed on the membership certificate.

Source PDF · 2026-04-01

KiwiCare

We don't cover any costs related to infertility or assisted reproduction.

Source PDF · 2026-04-01

RegularCare

Infertility or assisted reproduction is explicitly excluded: 'We don't cover any costs related to infertility or assisted reproduction.'

Source PDF · 2026-04-01

UltraCare

Infertility or assisted reproduction is explicitly excluded: 'We don't cover any costs related to infertility or assisted reproduction.'

Source PDF · 2026-04-01

Wellbeing Modules

Not on file.

Source PDF · 2026-04-01

Wellbeing One

We don't cover any costs related to infertility or assisted reproduction.

Source PDF · 2026-04-01

Wellbeing Two

We don't cover any costs related to infertility or assisted reproduction.

Source PDF · 2026-04-01

KiwiCare

Under the base Chemotherapy for cancer benefit, up to $8,000 each claims year is available for chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated for treatment of the diagnosed cancer (within the overall $48,000 annual limit). Under Cancer Cover Plus Chemotherapy 100 and Chemotherapy 300 upgrades, non-Pharmac approved but Medsafe-indicated chemotherapy drugs are covered without a separate sub-limit, up to $100,000 or $300,000 each claims year respectively. In all cases, 80% of actual charges is covered.

Source PDF · 2026-04-01

RegularCare

Under the 'Chemotherapy for cancer (base)' benefit, up to $8,000 each claims year is included within the overall $48,000 annual limit for chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated for treatment of the diagnosed cancer. Under the Cancer Cover Plus Chemotherapy 100 upgrade ($100,000 per claims year) and Chemotherapy 300 upgrade ($300,000 per claims year), non-Pharmac-approved but Medsafe-indicated chemotherapy drugs are covered without a separate sub-limit, subject to the overall annual cap. No specific Keytruda example is mentioned in the policy text.

Source PDF · 2026-04-01

UltraCare

Under the Chemotherapy for cancer (base) benefit, chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated for treatment of the diagnosed cancer are covered up to $10,000 each claims year (included within the overall $60,000 annual chemotherapy limit). Under Cancer Cover Plus upgrade options, non-Pharmac approved but Medsafe-indicated chemotherapy drugs are covered without a separate sub-limit, up to $100,000 each claims year (Chemotherapy 100) or $300,000 each claims year (Chemotherapy 300). Cancer Cover Plus excludes the specific cancer type for which a covered person has a defined family history of cancer (two or more biological siblings or parents diagnosed with colorectal, breast, ovarian, or prostate cancer before age 55, where the covered person was aware or should reasonably have been aware before applying); this exclusion does not apply to the base chemotherapy benefit.

Source PDF · 2026-04-01

Wellbeing Modules

Not on file.

Source PDF · 2026-04-01

Wellbeing One

Under the Chemotherapy for cancer (base) benefit, up to $10,000 each claims year is available for chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated for treatment of the cancer diagnosed, within the overall $60,000 annual limit. Under the Cancer Cover Plus upgrades (Chemotherapy 100: $100,000 per claims year; Chemotherapy 300: $300,000 per claims year), chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated are covered without a separate sub-limit up to the respective annual cap. The Cancer Cover Plus upgrade excludes cover for the specific cancer where a family history of cancer exclusion applies (two or more biological siblings or parents diagnosed with colorectal, breast, ovarian, or prostate cancer before age 55, where the insured was or should have been aware of the diagnosis before joining).

Source PDF · 2026-04-01

Wellbeing Two

Under the Chemotherapy for cancer (base) benefit, chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated for treatment of the cancer diagnosed are covered up to $10,000 each claims year, within the overall $60,000 annual limit. Under Cancer Cover Plus Chemotherapy 100 upgrade, non-Pharmac approved but Medsafe-indicated chemotherapy drugs are covered within the $100,000 annual limit with no separate sub-limit. Under Cancer Cover Plus Chemotherapy 300 upgrade, non-Pharmac approved but Medsafe-indicated chemotherapy drugs are covered within the $300,000 annual limit with no separate sub-limit.

Source PDF · 2026-04-01

KiwiCare

We'll cover up to 80% of the actual charges incurred for eligible healthcare services, up to the relevant policy limits. The policyholder is responsible for paying the remaining 20% co-payment (and any excess) directly to the health services provider. When using an Affiliated Provider contracted for the healthcare service, Southern Cross will cover 80% of the charges incurred up to policy limits unless Southern Cross or the Affiliated Provider advise otherwise. If actual charges exceed policy limits, the policyholder is responsible for paying the excess amount directly to the health services provider.

Source PDF · 2026-04-01

RegularCare

Southern Cross covers 80% of actual charges incurred for eligible healthcare services up to policy limits, unless the insurer or Affiliated Provider specifies otherwise. The member is responsible for paying the remaining 20% co-payment (the gap) plus any excess directly to the health services provider. When using an Affiliated Provider contracted for a service, Southern Cross covers 80% of charges up to relevant policy limits unless otherwise advised. Members must also pay any amount exceeding policy limits directly to the provider. If another insurer or person is liable to contribute, the amount covered by Southern Cross is reduced by any such payment.

Source PDF · 2026-04-01

UltraCare

When using an Affiliated Provider contracted for a healthcare service, Southern Cross covers 100% of the actual charges incurred for eligible healthcare services up to relevant policy limits, unless Southern Cross or the Affiliated Provider advise otherwise — no gap payment applies in this case. For non-Affiliated Providers, cover is limited to reasonable charges as determined by Southern Cross; the policyholder is responsible for paying any amount exceeding reasonable charges directly to the health services provider. The policyholder is also responsible for any amount exceeding policy limits. If a healthcare service is assessed under actual charges (rather than reasonable charges), the policyholder pays any amount above the policy limit.

Source PDF · 2026-04-01

Wellbeing Modules

Not on file.

Source PDF · 2026-04-01

Wellbeing One

Where Southern Cross covers 100% of actual charges (typically when an Affiliated Provider is used and unless otherwise advised), no gap applies to the insured. Where reasonable charges apply (typically for non-Affiliated Providers), the insured is responsible for paying any amount exceeding the reasonable charges directly to the health services provider. The insured is also responsible for paying any amount exceeding the policy limits and for paying any applicable excess directly to the health services provider.

Source PDF · 2026-04-01

Wellbeing Two

Where a healthcare service is performed by an Affiliated Provider, Southern Cross covers 100% of the actual charges incurred unless Southern Cross or the Affiliated Provider advises otherwise — in this case there is no gap for the member. Where Southern Cross covers the reasonable charges (typically when a non-Affiliated Provider is used), the member is responsible for paying any amount exceeding the reasonable charges directly to the health services provider. The member is also responsible for paying any amount exceeding the policy limits, and for paying any excess, directly to the health services provider.

Source PDF · 2026-04-01