Pharmac vs Non-Pharmac Drug Cover in NZ Health Insurance
NZ's Pharmac funds a defined list of medicines. Non-Pharmac drugs (including high-cost cancer drugs like Keytruda) are excluded from public funding. 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.
Source: each insurer's current policy wording PDF (linked inline). Last refreshed 2026-05-29.
AA Health
AA Health Everyday Cover
Wording effective 2026-05-16 · extraction confidence inferred ·
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Under the GP and Prescriptions Benefit, only pharmaceutical prescriptions for medicines that are funded by PHARMAC at the time of your treatment are covered. Medicines that aren't funded by PHARMAC at the time of your treatment are explicitly excluded.
AA Private Hospital Cover
Wording effective 2023-10-01 · extraction confidence inferred ·
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Base Cover only covers medications that are funded by PHARMAC for the treatment needed at the time of treatment (and registered/approved by Medsafe, prescribed and administered within Medsafe guidelines, prescribed by the treating specialist or GP). If the cost of a PHARMAC-funded medication is not fully funded by PHARMAC, the policy pays the difference up to the relevant benefit limit. Non-PHARMAC medicines are generally excluded under Base Cover. Exceptions: (1) Non-PHARMAC Cancer Treatment Benefit covers chemotherapy or immunotherapy medicines administered in a private hospital that are not funded by PHARMAC, up to $10,000 per insured person per policy year (must be Medsafe-approved and used within Medsafe approval). (2) Cancer Treatment at Home Benefit covers PHARMAC-funded chemotherapy medicines prescribed for home use, up to $10,000 per policy year. (3) The optional Non-PHARMAC Plus Benefit covers non-PHARMAC medicines (Medsafe-approved, used within Medsafe approval, not funded by PHARMAC) used in a private hospital or at home for up to six months after a covered private hospital admission, up to the selected benefit limit per policy year.
AA Private Hospital + Specialist Cover
Wording effective 2026-05-16 · extraction confidence inferred ·
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Medications claimed under the policy must be funded by PHARMAC for the treatment needed at the time of treatment (unless a specific benefit or Option covers non-PHARMAC medicines). If the cost of medication is not fully funded by PHARMAC but meets all criteria, the policy pays the difference up to the relevant benefit limit. Under the base Non-PHARMAC Cancer Treatment Benefit, chemotherapy or immunotherapy medicines administered in a private hospital that are not funded by PHARMAC are covered up to $10,000 per insured person per policy year, provided the medicines are approved by Medsafe; medicines administered or charged in a public hospital and medicines not approved by Medsafe are excluded. The Cancer Treatment at Home Benefit covers PHARMAC-funded chemotherapy medicines prescribed for use at home, up to $10,000 per insured person per policy year. The optional Non-PHARMAC Plus Benefit covers Medsafe-approved medicines not funded by PHARMAC, used in a private hospital or at home for up to six months post-admission, up to the benefit limit selected, with no excess required; medicines must be referred by a specialist and relate to an accepted claim under the Surgical, Non-Surgical, or Cancer Treatment Benefit.
Accuro
KidSmart
Wording effective 2026-05-16 · extraction confidence inferred ·
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Prescription drugs covered under modules (other than the non-Pharmac drugs benefit) must be listed under section A to I of the Pharmac Schedule (section H only applicable if used during a procedure in a private facility), Pharmac-approved, medically necessary, and prescribed by a registered medical practitioner; the child must meet Pharmac's funding criteria. Separately, the non-Pharmac subsidised drugs benefit under the Hospital and Surgical base plan covers all Medsafe-registered drugs regardless of Pharmac funding status, where treatment is prescribed by a registered medical specialist as appropriate, the condition is not otherwise excluded, and the drug is prescribed within Medsafe guidelines. If the drug qualifies for a government or other subsidy, only the remaining cost is reimbursed. All costs under the non-Pharmac drugs benefit are included within the maximum limit of the applicable surgical or non-surgical benefit; this benefit cannot be used with any benefit on an additional module.
SmartCare
Wording effective 2026-05-16 · extraction confidence inferred ·
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Unless outlined differently in the policy, prescription drugs must be listed under section A to I of the Pharmac Schedule (note that section H is only applicable if the drug is used during a procedure in a private facility), Pharmac-approved, medically necessary, and prescribed by a registered medical practitioner. Members must meet Pharmac's funding criteria and the drugs must be funded for the relevant claim. If prescription drugs require special authority from Pharmac to be covered, confirmation from the registered medical practitioner that the member meets the special authority criteria is required before cover can be assessed. Non-Pharmac-approved drugs are not covered under the prescription drug benefit.
SmartCare+
Wording effective 2026-05-16 · extraction confidence inferred ·
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Standard prescription drugs (under the GP+ module) must be listed under sections A to I of the Pharmac Schedule, Pharmac-approved, medically necessary, and prescribed by a registered medical practitioner; the member must meet Pharmac's funding criteria. As part of the Hospital and Surgical+ base plan, the Non-Pharmac subsidised drugs benefit covers all drugs registered by Medsafe for use in New Zealand where: the treatment is prescribed by a registered medical specialist as the appropriate medical treatment for the condition; the treatment or condition is not excluded elsewhere in the Health Plan document; and the drug is prescribed within the guidelines set by Medsafe. If the drug qualifies for a government or other subsidy, only the remaining cost is reimbursed. All costs under the non-Pharmac drugs benefit are included in the maximum limit of the surgical or non-surgical benefit (whichever applies) under the Hospital and Surgical+ base plan, and the non-Pharmac drugs benefit cannot be used with any benefit on an additional module. No specific Keytruda example is mentioned.
SmartStay
Wording effective 2026-05-16 · extraction confidence inferred ·
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Unless outlined differently in the policy, prescription drugs must be listed on the Pharmac Schedule (note that section H is only applicable if the drug is used during a procedure in a public or private hospital/facility), Pharmac-approved, medically necessary, and prescribed by a registered medical practitioner. Members must meet Pharmac's funding criteria and the drugs must be funded for the relevant claim. If special authority from Pharmac is required, confirmation from the registered medical practitioner that the member meets the special authority criteria is needed before cover can be assessed. Non-Pharmac drugs are not covered. Chemotherapy drugs administered orally at home that are prescribed by a registered medical specialist and used during an approved cycle of chemotherapy treatment are covered under the private and public hospital medical admission benefit.
StaffCare
Wording effective 2026-05-16 · extraction confidence verified ·
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Prescription drugs are only covered under the GP module (up to $20 per item, maximum $300 per person per policy year) for drugs ordered by a New Zealand-registered medical practitioner or registered medical specialist. Chemotherapy drugs administered orally at home that are prescribed by a registered medical specialist and used during an approved cycle of chemotherapy treatment are covered under the Non-surgical cancer treatment benefit. Other prescription drugs used during hospital admission are covered as part of the Private hospital medical admission and Non-surgical cancer treatment benefits. No explicit PHARMAC vs non-PHARMAC distinction or Keytruda-specific rules are stated in the policy wording.
StaffCare+
Wording effective 2026-05-16 · extraction confidence inferred ·
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Prescription drugs (outside hospital) must be listed under section A to I of the Pharmac Schedule (section H only if used during a procedure in a private facility), Pharmac-approved, medically necessary, and prescribed by a registered medical practitioner; Pharmac funding criteria and special authority requirements must be met. As part of the Hospital and Surgical+ base plan, the non-Pharmac cancer drugs benefit covers Medsafe-registered cancer drugs up to $40,000 per person per policy year regardless of whether the drug qualifies for a government or other subsidy such as Pharmac funding; if the drug does qualify for a subsidy, only the remaining cost is reimbursed. All costs under the non-Pharmac cancer drugs benefit are included within the maximum limit of the General surgery benefit or the Non-surgical cancer treatment limit under the Private hospital medical admission benefit, whichever applies.
AIA
nib
Easy Health
Wording effective 2019-12-19 · extraction confidence unknown ·
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Not on file for this product.
Source: https://www.nib.co.nz/Documents/Document/EasyHealthBrochure.pdf
Ultimate Health
Wording effective 2019-12-19 · extraction confidence unknown ·
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Not on file for this product.
Source: https://www.nib.co.nz/Documents/Document/UltimateHealthBrochure.pdf
Ultimate Health Max
Wording effective 2018-12-23 · extraction confidence unknown ·
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Not on file for this product.
Source: https://www.nib.co.nz/Documents/Document/UltimateHealthMaxPolicyDocument20170701.pdf
Southern Cross
KiwiCare
Wording effective 2026-04-01 · extraction confidence verified ·
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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.
RegularCare
Wording effective 2026-04-01 · extraction confidence verified ·
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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.
UltraCare
Wording effective 2026-04-01 · extraction confidence inferred ·
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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.
Wellbeing Modules
Wording effective 2026-04-01 · extraction confidence low ·
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Prescriptions cover excludes cover for drugs that are not Pharmac approved
Wellbeing One
Wording effective 2026-04-01 · extraction confidence inferred ·
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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.
Wellbeing Two
Wording effective 2026-04-01 · extraction confidence inferred ·
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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.
UniMed
Health Positive
Wording effective 2016-01-22 · extraction confidence unknown ·
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Not on file for this product.
Hospital Select
Wording effective 2018-01-25 · extraction confidence unknown ·
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Not on file for this product.
ParentStay
Wording effective 2025-10-01 · extraction confidence inferred ·
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All prescription drugs and medication covered under the policy must be: registered and approved by Medsafe for use in New Zealand; prescribed and used within the guidelines set by Medsafe; Pharmac-approved and listed on the Pharmac Schedule under sections A to H, for the treatment being received in New Zealand; medically necessary; and prescribed by the treating specialist or GP. If the prescription drug requires special authority from Pharmac, confirmation that the member meets the special authority criteria is required before cover can be assessed. Under the Cancer Care benefit, only Pharmac-approved prescription drugs are covered. Non-Pharmac-funded drugs are not covered.
Source: https://www.unimed.co.nz/assets/PlansAndDocs/Health-Plans/ParentStay-Health-Plan-2025.pdf
UniCare Advantage
Wording effective 2025-08-01 · extraction confidence low ·
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Pharmac-approved chemotherapy drugs are covered under the Chemotherapy benefit (up to $55,000 per policy year). Non-Pharmac chemotherapy drugs that are Medsafe approved for the treatment of cancer are covered up to $8,500 per annum within the Chemotherapy benefit. Non-Pharmac subsidised pharmaceuticals (prescribed by a Registered Medical Practitioner, approved by Medsafe, and not fully or partly subsidised by Pharmac through the New Zealand Pharmaceutical Schedule) are covered up to $330 per policy year under both the In-Patient Non-Pharmac Subsidised Pharmaceuticals benefit and the General Medical Expenses Non-Pharmac Subsidised Pharmaceuticals benefit. User part charges for prescription items on the New Zealand Pharmaceutical Schedule are covered up to $240 per policy year.
Source: https://www.unimed.co.nz/assets/PlansAndDocs/Health-Plans/UniCare_Advantage_Plan.pdf
Machine-readable version
Same content as plain text: /api/topic/pharmac-vs-non-pharmac/summary.md
Per-product JSON facts: see llms.txt for the full endpoint list.
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