Claim reasons

Medicine not on the list

The scheme says the medicine claimed is not on the list it funds for your option.

Build my letter

Words you might see
  • “not on the formulary”
  • “medicine list”
  • “generic reference price”
  • “MMAP”

Questions to ask

  1. Please provide the formulary applicable to my option, showing the entry for the medicine claimed.
  2. Which alternative on that formulary does the scheme consider clinically appropriate for my condition?
  3. What is the scheme’s formulary exception process where the listed alternatives are not clinically suitable?
  4. Was the medicine claimed prescribed for a Prescribed Minimum Benefit condition, and how was that assessed?
Details to have ready
  • Whether your prescriber has recorded a clinical reason for this specific product.
  • Whether you have tried the alternatives the scheme funds, and what happened.

All claim reasons

Pryse is not a law firm and does not act for you. Nothing here is a determination of your rights or legal advice, and no registered scheme rule is quoted. The questions ask your scheme to provide its own.