Document ID: chunk:federal_register_of_legislation:F2024C01114:schedule:4
Version: federal_register_of_legislation:F2024C01114
Segment Type: schedule
Provision Reference: sch 4
Character Range: 94978–99587

Schedule 4—Product tiers and clinical categories
Note: See rule 4 and Part 2B.

1.  Product tiers and clinical categories
  For the definition of gold policy, silver policy, bronze policy and basic policy in rule 4, and for rule 11H, the following table sets out the clinical categories that are indicated for policies of each product tier.

Clinical category                                               Basic  Bronze  Silver  Gold
Rehabilitation                                                  R     R      R      
Hospital psychiatric services                                   R     R      R      
Palliative care                                                 R     R      R      
Brain and nervous system                                        RCP                  
Eye (not cataracts)                                             RCP                  
Ear, nose and throat                                            RCP                  
Tonsils, adenoids and grommets                                  RCP                  
Bone, joint and muscle                                          RCP                  
Joint reconstructions                                           RCP                  
Kidney and bladder                                              RCP                  
Male reproductive system                                        RCP                  
Digestive system                                                RCP                  
Hernia and appendix                                             RCP                  
Gastrointestinal endoscopy                                      RCP                  
Gynaecology                                                     RCP                  
Miscarriage and termination of pregnancy                        RCP                  
Chemotherapy, radiotherapy and immunotherapy for cancer         RCP                  
Pain management                                                 RCP                  
Skin                                                            RCP                  
Breast surgery (medically necessary)                            RCP                  
Diabetes management (excluding insulin pumps)                   RCP                  
Heart and vascular system                                       RCP                   
Lung and chest                                                  RCP                   
Blood                                                           RCP                   
Back, neck and spine                                            RCP                   
Plastic and reconstructive surgery (medically necessary)        RCP                   
Dental surgery                                                  RCP                   
Podiatric surgery (provided by a registered podiatric surgeon)  RCP                   
Implantation of hearing devices                                 RCP                   
Cataracts                                                       RCP                    
Joint replacements                                              RCP                    
Dialysis for chronic kidney failure                             RCP                    
Pregnancy and birth                                             RCP                    
Assisted reproductive services                                  RCP                    
Weight loss surgery                                             RCP                    
Insulin pumps                                                   RCP                    
Pain management with device                                     RCP                    
Sleep studies                                                   RCP                    

    Indicates the clinical category is a minimum requirement of the product tier.  The clinical category must be covered on an unrestricted basis.
R   Indicates the clinical category is a minimum requirement of the product tier.  The clinical category may be offered on a restricted cover basis in Basic, Bronze and Silver product tiers only.
RCP  Restricted cover permitted: indicates the clinical category is not a minimum requirement of the product tier. Insurers may choose to offer these as additional clinical categories on a restricted or unrestricted basis.
     A blank cell indicates that the clinical category is not a minimum requirement of the product tier. Insurers may choose to offer these as additional clinical categories; however it must be on an unrestricted basis.