Southern Cross vs nib — Health Insurance
Side-by-side verified policy facts. Every entry cites its source wording PDF.
Southern Cross
Southern Cross Medical Care Society · website ↗
- RBNZ rating
- A+ (S&P, Strong, Stable — Dec 2024)
- Active products
- 6
nib
nib nz limited · website ↗
- RBNZ rating
- A (S&P, Strong, Stable — upgraded Feb 2024)
- Active products
- 3
Pharmac vs non-Pharmac drug cover
NZ's Pharmac funds a defined list of medicines. A medicine that is not on the Schedule, or is funded only for other conditions (Keytruda is funded for some cancers and not others), is not publicly funded for you. Health insurance can fill that gap — but every insurer handles it differently. This page summarises each NZ insurer's non-Pharmac rules verbatim from their policy wordings.
Southern Cross
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
nib
Easy Health
Medications must be registered and approved by Medsafe, prescribed and administered within Medsafe guidelines, prescribed by the treating specialist or GP, and funded by PHARMAC for the treatment needed at the time of treatment. If the cost is not fully funded by PHARMAC but meets these criteria, nib pays the difference up to the relevant benefit limit. Medications not funded by PHARMAC are generally excluded. The Non-PHARMAC Cancer Treatment Benefit covers chemotherapy or immunotherapy medicines administered in a private hospital that are not funded by PHARMAC at time of treatment and are Medsafe-approved, up to $20,000 per insured person per policy year (deducted from overall benefit limit); medicines administered or charged in a public hospital and non-Medsafe-approved medicines are excluded under this benefit. The Non-PHARMAC Plus Option (if selected) covers Medsafe-approved medicines not funded by PHARMAC, used in a private hospital or at home for up to six months post-admission for approved treatment, up to the benefit limit per policy year; no excess applies; hospital services are not covered under this Option. Medications issued solely for home use (unless covered under a specific benefit), prescribed in a public hospital, or used for a purpose not funded by PHARMAC are not covered.
Source PDF · 2024-09-20
Ultimate Health
Cancer Treatment Benefit covers medications administered in a private hospital as part of chemotherapy, immunotherapy, radiotherapy or brachytherapy up to the Non-Surgical Benefit limit. The Non-PHARMAC Cancer Treatment Benefit separately covers chemotherapy or immunotherapy medicines administered in a private hospital that are not funded by PHARMAC at the time of treatment, up to $20,000 per insured person every policy year (deducted from the overall benefit limit). Medicines administered or charged in a public hospital are not covered under the Non-PHARMAC benefit, nor are medicines not approved by Medsafe.
Source PDF · 2025-11-24
Ultimate Health Max
Medicines funded by PHARMAC are covered as in-hospital pharmaceutical prescriptions under the Surgical and Non-Surgical Benefits. Non-PHARMAC funded medicines are covered under the Non-PHARMAC Funded Medicines in Hospital Benefit (up to the remaining Surgical or Non-Surgical Benefit limit) and the Non-PHARMAC Funded Medicines at Home Benefit (for up to six months after private hospital admission, up to the remaining Surgical or Non-Surgical Benefit limit), provided the medicine is approved by Medsafe and used within Medsafe approval. The Non-PHARMAC Plus Option provides an additional benefit limit (specified on the Acceptance or Renewal Certificate) for non-PHARMAC funded medicines after specialist referral, covering medicines approved by Medsafe and used within Medsafe approval, that are not funded by PHARMAC at the time of treatment. No specific Keytruda example is mentioned in the available text.
Source PDF · 2024-02-01
Compare this topic across every NZ insurer → /topics/pharmac-vs-non-pharmac/
ACC interaction
In NZ, ACC covers accidental injury and treatment-injury costs. Health insurance generally excludes ACC-covered events but most policies offer an ACC Top-Up benefit for any shortfall. This page summarises each insurer's ACC interaction rules verbatim.
Southern Cross
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 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
nib
Easy Health
Injuries covered by ACC are a general exclusion and are not covered under this policy. The ACC Top-Up Benefit covers the difference if ACC claim payments do not fully cover the cost of surgery or medical treatment for a physical injury, up to the benefit limit remaining on the Surgical or Non-Surgical Benefit; injuries that occurred before the join date are not covered under this benefit. The Cover in Australia Benefit excludes surgery or treatment relating to an injury which would be covered under ACC if it had happened in New Zealand. If nib believes ACC should pay for a health service rather than nib, nib may ask ACC to review their decision on the policyholder's behalf, requiring full cooperation including granting legal authority, providing case summaries and ACC decline letters, and other relevant information. The Public Hospital Payment benefit does not cover any admission related to an acute condition.
Source PDF · 2024-09-20
Ultimate Health
Injuries that are covered by ACC are excluded from cover. The ACC Top-Up Benefit pays the difference if ACC claim payments don't fully cover the cost of surgery or medical treatment for a physical injury, up to the benefit limit remaining on the Surgical or Non-Surgical Benefit. Injuries that occurred before the join date are not covered under the ACC Top-Up Benefit. The ACC Treatment Injury Benefit covers surgery or treatment needed to treat or repair an injury sustained during a health service paid for by nib, to the extent not covered by ACC, up to the remaining Surgical or Non-Surgical Benefit limit. If nib has paid for treatment and ACC reimburses the insured person, the reimbursement must be forwarded to nib.
Source PDF · 2025-11-24
Ultimate Health Max
The ACC Top-Up Benefit covers the difference between what ACC pays and the cost of surgery or medical treatment for a physical injury, up to the remaining Surgical or Non-Surgical Benefit limit. Injuries that occurred before the join date are excluded. If ACC reimburses the insured person after nib has paid, the reimbursement must be forwarded to nib. Under the Cover in Australia Benefit, surgery or treatment relating to an injury that would be covered under ACC if it had happened in New Zealand is excluded. The ACC Treatment Injury Benefit covers surgery or treatment needed to treat or repair an injury sustained during a health service paid for by nib that is not covered by ACC, up to the remaining Surgical or Non-Surgical Benefit limit; if ACC declines to pay, nib may request an ACC review on the insured person's behalf.
Source PDF · 2024-02-01
Compare this topic across every NZ insurer → /topics/acc-interaction/
Mental health cover
Mental health cover varies dramatically across NZ health insurers — from entirely excluded (entry-level plans) to specific psychiatric hospitalisation sublimits. This page lists each insurer's mental-health rules with the relevant NZD sublimits and admission terms.
Southern Cross
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 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
nib
Easy Health
MH sublimit: Not covered — psychiatric, psychological, behavioural, or developmental conditions (for example: depression, ADHD, and eating disorders) are a general exclusion with no sublimit provided.
Psychiatric, psychological, behavioural, or developmental conditions (for example: depression, ADHD, and eating disorders) and injuries that are self-inflicted are general exclusions under this policy. There is no inpatient mental health admission benefit.
Source PDF · 2024-09-20
Ultimate Health
MH sublimit: psychiatric, psychological, behavioural, or developmental conditions (for example: depression, ADHD, and eating disorders) are excluded entirely — no sublimit applies as these conditions are not covered
Psychiatric, psychological, behavioural, or developmental conditions (for example: depression, ADHD, and eating disorders) are listed as a general exclusion. There is no inpatient mental health admission benefit under this policy.
Source PDF · 2025-11-24
Ultimate Health Max
No specific mental health admission rules or sublimits are described in the available policy text.
Source PDF · 2024-02-01
Compare this topic across every NZ insurer → /topics/mental-health-cover/
Pre-existing conditions
NZ health insurers handle pre-existing conditions in two main ways: (1) disclose-and-accept (Southern Cross — exclude unless noted on certificate), or (2) stand-down period (nib — 3 years then covered, with permanent exclusions for certain conditions). This page lists each insurer's verbatim rules.
Southern Cross
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 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
nib
Easy Health
A pre-existing condition is any sign, symptom, treatment, or surgery of any condition that happened on or before the insured person's join date that the policyowner(s) or another insured person were aware of, had an indication that something was wrong, sought investigation or medical advice for, or would cause a reasonable person to seek diagnosis, care, or treatment. In the first three years following the join date, no claims that directly or indirectly relate to any pre-existing conditions will be paid. After three years of continuous cover following the join date, eligible pre-existing conditions are covered. Some pre-existing conditions are never covered: pre-existing cardiovascular conditions (including congenital or acquired conditions, or conditions where specified risk factors applied at start/join date); pre-existing cancers (pre-malignant pre-existing cancers may be covered if there has been appropriate specialist/GP treatment); pre-existing hip or knee conditions (including degenerative conditions, disease, or injury); pre-existing back conditions (including spinal cord, vertebrae, soft tissues, and joints of the spine, and previous back surgery); transplant surgery (and any follow-up or complications); reconstructive or reparative surgery performed before the join date (including repairing scars and treating complications). If a dependent child is added within four months of birth, their pre-existing conditions are covered under Base Cover (general exclusions including congenital conditions still apply).
Source PDF · 2024-09-20
Ultimate Health
Personal exclusions (usually pre-existing conditions) are listed on the Acceptance or Renewal Certificate and are not covered. For the Specialist Option and GP Option and Dental, Optical, and Therapeutic Option, if a dependent child is added within four months of birth, their pre-existing conditions are covered under those Options except for congenital conditions. Hereditary or genetic conditions are excluded in the absence of signs or symptoms that a condition exists from your join date. The Acceptance or Renewal Certificate may also include loadings for specific health risks.
Source PDF · 2025-11-24
Ultimate Health Max
Pre-existing conditions may be excluded as personal exclusions listed on the Acceptance or Renewal Certificate. If a dependent child is added to the Specialist Option, GP Option, or Dental, Optical, and Therapeutic Option within four months of birth, their pre-existing conditions are covered under those Options, except for any congenital conditions.
Source PDF · 2024-02-01
Compare this topic across every NZ insurer → /topics/pre-existing-conditions/
IVF and assisted reproduction
IVF, infertility treatment, and assisted reproduction are excluded from virtually every NZ retail health insurance policy. This page documents each insurer's stance verbatim.
Southern Cross
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 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
nib
Easy Health
IVF is not covered. Assisted reproduction and infertility are listed as general exclusions under the Reproductive Health category. The High-Risk Pregnancy Benefit specifically states that IVF is not considered a risk factor.
Source PDF · 2024-09-20
Ultimate Health
IVF is not covered. Assisted reproduction is listed as a general exclusion under Reproductive Health. The High-Risk Pregnancy Benefit explicitly states 'we don't consider IVF to be a risk factor' and infertility is also excluded.
Source PDF · 2025-11-24
Ultimate Health Max
IVF is not considered a risk factor under the High-Risk Pregnancy Benefit and is therefore not covered under that benefit. No other IVF cover is described in the available policy text.
Source PDF · 2024-02-01
Compare this topic across every NZ insurer → /topics/ivf-and-assisted-reproduction/
Oncology and high-cost cancer drugs
Pharmac funds many cancer medicines only for particular cancers or stages, so a high-cost drug can be funded for one patient and not another. Some NZ insurers cover these via separate cancer benefits with specific NZD caps. This page summarises each insurer's oncology / non-Pharmac chemotherapy cover.
Southern Cross
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 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
nib
Easy Health
The Non-PHARMAC Cancer Treatment Benefit (Base Cover) pays for chemotherapy or immunotherapy medicines administered in a private hospital that are not funded by PHARMAC at time of treatment and are Medsafe-approved, up to $20,000 per insured person per policy year, deducted from the overall Non-Surgical Benefit limit. Medicines administered or charged in a public hospital, and non-Medsafe-approved medicines, are excluded. The Non-PHARMAC Plus Option (if selected) provides additional cover for Medsafe-approved, non-PHARMAC-funded medicines (including those used at home for up to six months post-admission for approved treatment), up to the Option benefit limit per policy year, with 100% of eligible costs covered and no excess. No specific mention of Keytruda by name in the policy text.
Source PDF · 2024-09-20
Ultimate Health
Non-PHARMAC Cancer Treatment Benefit: covers chemotherapy or immunotherapy medicines administered in a private hospital that are not funded by PHARMAC at the time of treatment, up to $20,000 per insured person every policy year, deducted from the overall benefit limit. Medicines administered or charged in a public hospital are excluded. Medicines not approved by Medsafe are excluded.
Source PDF · 2025-11-24
Ultimate Health Max
Non-PHARMAC funded medicines required in a private hospital are covered under the Non-PHARMAC Funded Medicines in Hospital Benefit up to the remaining Surgical or Non-Surgical Benefit limit (up to $600,000 surgical / $300,000 non-surgical per policy year). Non-PHARMAC funded medicines used at home for up to six months after private hospital admission are covered under the Non-PHARMAC Funded Medicines at Home Benefit up to the remaining Surgical or Non-Surgical Benefit limit. The Non-PHARMAC Plus Option provides a separately specified benefit limit (as stated on the Acceptance or Renewal Certificate) for non-PHARMAC funded medicines after specialist referral, in hospital or at home. All such medicines must be approved by Medsafe and used within Medsafe approval.
Source PDF · 2024-02-01
Compare this topic across every NZ insurer → /topics/oncology-high-cost-drugs/
Gap payment rules
When a provider's charges exceed what the insurer pays, the member pays the 'gap'. NZ insurers use different models — affiliated/preferred provider networks, percentage co-pays, 'reasonable charges' caps. This page lists each insurer's gap rules verbatim.
Southern Cross
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 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
nib
Easy Health
If you choose a recognised provider that is part of the First Choice Network, nib covers 100% of eligible costs up to the benefit limit, less any excess. If you choose a recognised provider that is not part of the First Choice Network, a gap payment may apply — the gap payment is the difference between what the provider charges and the Efficient Market Price (the maximum nib will pay for a service by a non-First Choice provider). The Efficient Market Price is determined based on what healthcare providers charge, nib's claims data, and nib's experience with New Zealand's health market. If a pre-approval was obtained, the Efficient Market Price at the pre-approval date applies; if not, the Efficient Market Price at the treatment date applies. The excess (chosen by the policyowner) applies once per insured person per policy year for any accepted claim and must be paid directly to the recognised provider along with any gap payments.
Source PDF · 2024-09-20
Ultimate Health
The policy pays 80% or 100% of eligible costs depending on the benefit and whether the diagnostic investigation is listed on the Diagnostics Schedule. For benefits paying 80%, the insured person bears the remaining 20% co-payment. For benefits listed on the Diagnostics Schedule, 100% of eligible costs are paid up to the available benefit limit. The Specialist Option pays 80% of eligible costs for specialist consultations and diagnostic tests. No explicit gap payment arrangement between nib and providers (such as a no-gap or known-gap scheme) is described in this document.
Source PDF · 2025-11-24
Ultimate Health Max
The policy pays 100% of eligible costs up to the available benefit limit for Base Cover and most Options (Specialist Option, Non-PHARMAC Plus Option, GP Option). The Dental, Optical, and Therapeutic Option pays 80% of eligible costs up to the available benefit limit. The Medical Tourism Benefit pays a maximum of 75% of the usual, customary and reasonable charges that would have been payable in New Zealand. The Cover in Australia Benefit and Delayed Treatment Benefit pay up to the usual, customary and reasonable charges that would have been payable in New Zealand, up to the overall benefit limit. Payments are made in New Zealand Dollars to the selected New Zealand bank account of the policyowner or insured person and are not paid directly to the health service provider for overseas treatment benefits.
Source PDF · 2024-02-01
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