Categories
BLOG

does health insurance cover medical cannabis

Does Medicare or Health Insurance Cover Medicinal Cannabis?

The most common question asked about medicinal cannabis has been “is it covered by Medicare, PBS or my Private Health Insurance?”.

Medicare generally covers in-person Cannabis Clinic consultations. PBS does not provide rebates for medicinal cannabis products like CBD or THC oil. A few select Health Funds cover medical cannabis products as a non-PBSprescription.

With the support of the government, cannabis medicines will be added to the Pharmaceutical Benefits Scheme (PBS).

This will allow for subsidised medicine costs and encourage health funds to support this treatment.

Table of Contents.

What is medical cannabis?

Medicinal cannabis is a new therapeutic medicine that effectively treats various medical conditions; most famous for treating epilepsy, arthritis and cancer-related symptoms.

The most common extracts from the cannabis plant used in medicine are cannabidiol (CBD) and Tetrahydrocannabinol (THC).

Both have different medicinal effects and doctors usually prescribe a mixture of the two; an example would be 10% THC and 20% CBD in a 50ml oil bottle (remaining 70% is olive oil or hemp seed oil).

Cannabis comes in various forms, including:

  • dry cannabis herb (flower or bud)
  • oils
  • sprays
  • patches
  • gels
  • creams

Your regular GP’s or Cannabis Clinic doctors can prescribe you with medicinal marijuana.

Does the government cover medical cannabis?

Medical cannabis is not listed on the Pharmaceutical Benefits Scheme (PBS), and that generally makes it not applicable for subsidised costs.

Cannabis medicines being listed on the PBS program benefits you by having the cost of medications subsidised. This makes medicine both affordable and more accessible to all Australians.

Medicare does cover rebates for In-person cannabis clinic, and Medicare Rebates cover GP consultations.

Over the phone or online doctor consultations, however, are not covered by Medicare Rebates.

In the near future, we are expecting to see medicinal cannabis products added to the PBS program, and this will see a significant price drop the approved medicines.

Does Private Health Insurance cover cannabis?

Private Health Funds have various levels of cover, and even with the highest level, a lot of patients are out of luck.

The majority of Private Health Insurance companies do not support medicinal cannabis consultations and cannabis medicines.

How do I know if my health insurance covers medicinal cannabis?

When reading through your cover or speaking with your Private Health Fund, check:

  • 1) covers medicinal cannabis prescriptions
  • 2) covers non-PBS listed prescriptions
  • 3) consultations for non-PBS listed prescription

When medicinal cannabis becomes recognised as a “first-line therapy” in Australia, then we will see more Health Funds support the treatment.

Which Health Funds cover medical cannabis?

The current list of health insurance providers that cover non-PBS pharmaceuticals include:

As the terms and conditions often change, check with the insurance provider’s exclusion list to ensure that they have not further excluded medicinal cannabis.

Most medicinal cannabis products are classified as non-PBS pharmaceuticals, and confirming this with your doctor before filling your prescription could save you hundreds!

The steps to claim non-PBS prescriptions are:

  • receive the prescription for non-PBS medicinal cannabis products
  • order and pay the full amount
  • submit the receipt and claim to your health insurance provider

James King

James is an experienced writer and legal cannabis advocate in Australia. He answers all the questions about business, legalisation and medicinal cannabis.

Disclaimer: Cannabis Place are not doctors and we recommend consulting health professionals for accurate information. This site may contain information regarding drugs. This content is designed for an 18+ audience. Click here for our full disclaimer

Find out how you are covered for medicinal cannabis products (non-pbs) and doctor consultations for treatment. You may be covered for CBD and THC oil.

Why Health Insurance Won’t Pay for Medical Marijuana

James Lacy, MLS, is a fact checker and researcher. James received a Master of Library Science degree from Dominican University.

istockphoto / Getty Images

If you live in a state where medical marijuana use has been legalized (35 states and DC as of late 2020), it’s tempting to assume that your health insurance will pay for it like other drugs prescribed by your physician. However, you’d be wrong; health insurance won’t pay for medical marijuana even in states where its use has been legalized. Why won’t health insurance pay for medical marijuana when it will pay for all sorts of other drugs, many arguably more dangerous and prone to abuse?  

Medical Marijuana Is a Schedule I Drug

Health insurers in the United States won’t pay for anything that’s technically illegal. Most health insurance policies include an illegal acts exclusion saying that health issues occurring due to or in association with your voluntary involvement in an illegal act are not covered (some states limit or prohibit these sort of exclusions  ). Even though medical marijuana has most likely been legalized in the state where you live, it’s still classified by the federal government as a schedule I controlled substance as defined by the Controlled Substances Act. It’s still illegal to use marijuana in terms of federal law.  

In addition to health plan illegal acts exclusion clauses, another issue arises due to marijuana’s Schedule I designation. Schedule I controlled substances can’t be prescribed by physicians the way other medications are.

Physicians who prescribe controlled substances must be registered with the Drug Enforcement Administration and have a DEA number. Prescribing a Schedule I drug, even in a state where medical marijuana has been legalized, would place a physician at risk of having his or her DEA registration revoked. Even if medical marijuana has been legalized in your state, as long as it’s considered a Schedule I drug by the federal government, prescribing it would put your physician at risk of losing his or her ability to prescribe even simple controlled substances like sleeping pills and cough syrup with codeine.  

For this reason, most physicians don’t prescribe medical marijuana. In states that have legalized its use, physicians recommend medical marijuana rather than prescribe it (Cigna describes how a doctor can write a “certificate” that the patient can take to a medical marijuana dispensary).   That brings us to stumbling block number two.

Health Insurance Won’t Pay for Medical Marijuana If It’s Not on the Drug Formulary

Even if the U.S. were to change marijuana to a schedule II or III drug—thereby allowing its prescription and decriminalizing its medical use across the country—your health insurance company probably still wouldn’t pay for your medical marijuana. Likewise, if congressional action were to remove marijuana from the list of controlled substances altogether, your health plan probably still wouldn’t pick up the tab for your Alice B. Toklas brownies even if your doctor recommended them.

Each health plan has a drug formulary, a list of medications it covers for health plan members. Your health plan’s pharmacy and therapeutics committee would have to add marijuana to its drug formulary before it would be a covered benefit of your health insurance.  

It would be highly unusual for a health plan to add a drug to its formulary if the drug hasn’t been FDA approved. Getting new drug approval from the FDA requires clinical studies to determine both the drug’s safety and that the drug is effective. Clinical studies are complicated and expensive to perform. So, when the FDA grants a new drug approval, it also grants a period of time in which the company given the new drug approval has exclusive rights to manufacture and sell the drug in the United States.  

If you think it costs a lot now, wait until Pfizer, Merck, AstraZeneca or another big pharma company gains the exclusive right to bring marijuana to market in the United States.

Without FDA approval, it won’t get on your health plan’s drug formulary, so your health insurance won’t pay for medical marijuana. The process of getting marijuana approved would almost assuredly involve big pharma, exclusive marketing rights, and exorbitant costs. You can read more about this in an article about marijuana that the FDA published.

The FDA has, however, approved Marinol (in 1985), Cesamet (in 2006), and more recently, Syndros (in 2016). All three contain a synthetic form of THC.   In 2018, the FDA approved Epidiolex, a CBD oral solution for treating seizures associated with two forms of epilepsy. Although these drugs are not the same thing as cannabis, they can be prescribed just like any other FDA-approved medication, and do tend to be covered by health insurance plans.  

Health Insurance Won’t Pay for Medical Marijuana as an Herbal Remedy

If marijuana was to be reclassified so that it wasn’t a controlled substance at all, it might become available without a prescription. However, those who think that’s the answer to getting medical marijuana covered by health insurance are misguided.

When a drug becomes available without a prescription, it’s removed from health plan drug formularies and you’re expected to pay for it yourself. Does your health insurance currently reimburse you for over-the-counter medications like Tylenol? Most don’t. Does it cover herbal remedies like St. John’s wort or echinacea? That’s unlikely.

In this situation, patients who would benefit from using marijuana would be able to buy it over-the-counter like any other herbal remedy. As they are now, those patients would be highly motivated to find a way to pay for it themselves. Why would your health insurance want to set a precedent of paying for over-the-counter drugs or herbal remedies that you’re willing to pay for yourself?

Will Things Change?

In summary, there’s more than one reason why your health plan won’t pay for medical marijuana. Even if marijuana were to be reclassified to a lower schedule or congressional action removed it from the list of controlled substances altogether, that wouldn’t be like waving a magic wand. Your health plan wouldn’t magically start paying for your medical marijuana a month or two later. Instead, it would be the beginning of a long, slow, process.

If the process ended up with marijuana being an FDA approved drug, it might eventually be covered by your health plan as a prescription drug on its drug formulary.   However, that would be years, not months, down the road. If, even more surprisingly, marijuana ended up as an herbal remedy not requiring FDA approval, it remains highly unlikely that your health insurance would pay for it.

Learn about why health insurance won't pay for medical marijuana, and why reclassification of marijuana won't make your health plan pay either.