Automatically approved treatment
These costs are approved automatically for your accepted condition:
- doctor visits
- medicines for approved treatment if on PHARMAC's list of subsidised medicines
- diagnostic x-rays and scans up to NZD$1,000 each, if linked to approved treatment. All MRIs need pre-approval.
Any other costs must be pre-approved except in an emergency situation when you:
- can’t reasonably seek and get pre-approval, and
- can’t get the treatment through the public health system.
You can seek pre-approval through your case manager.
We’ll usually only fund medicines on PHARMAC's subsidised list.
Your doctor can apply for medicines not on the list. If PHARMAC declines this, we may consider funding the medicine ourselves. We’d need copies of the application to PHARMAC and the decision. We look at:
- research-based evidence the medicine works
- your situation and needs
We can approve a course of treatment for up to 12 months or 12 sessions, whichever’s less. We need full details from the provider, including expected outcomes.
Before deciding on further sessions we need a full report from the provider and may seek a second medical opinion.
We can fund food substitutes. These must be prescribed by the treatment provider. This treatment provider should first apply to PHARMAC for special authority.
Specialist and private hospital treatment
Requests for specialist or private hospital treatment are assessed case by case. Specialist treatment should be in your local area, where possible.
Services to support treatment
We can fund other services, such as accommodation or laboratory tests, you need to:
- have an approved treatment, and
- meet its goals.
We can fund alternative treatment if:
- you have tried all the available standard treatment, and
- an approved treatment provider has prescribed—and is monitoring—a trial period, complete with outcomes measures.
Your approved treatment provider will set these outcomes measures in consultation with you.
We won’t fund alternative treatment if you could have had standard treatment but refused.
If you're living overseas the treatment must meet these conditions:
- Generally accepted in NZ.
- Carried out by a certified practitioner, registered with the relevant professional body.
We won’t pay costs covered by the public-health or accident-compensation system of your country of residence.