Phoenix Health Fund’s Top Hospital Essentials $500 Excess and Mid Extras offers Members all the same great comprehensive benefits as our Top Hospital cover, but removes coverage for Pregnancy services, Assisted reproductive services, Gastric Banding and Psychiatric is restricted to help you save money.  Additionally, with this combination you get a great Mid Extras package for services such as dental, optical and physiotherapy and much more.

What’s Included in Hospital Cover

Treatments Covered
Treatment for injuries sustained in an accident Yes
Prosthesis Yes
Appendicitis treatment Yes
Removal of Appendix Yes
Obesity Surgery No
Removal of tonsils and adenoids Yes
Joint reconstruction and investigations Yes
Surgical removal of wisdom teeth (hospital charge only) Yes
Colonoscopy/Gastroscopy Yes
Pregnancy and birth related services No
Fertility treatment (e.g IVF & GIFT programs) No
Heart related services Yes
Major eye surgery (including cataract and eye lens services) Yes
Joint replacements Yes
Surgery on broken bones Yes
Renal dialysis Yes
Cosmetic surgery covered by Medicare Yes
Cosmetic surgery (not covered by Medicare) No
Psychiatric services Restricted
Rehabilitation Yes
Palliative care Yes
All other in-patient services where a Medicare benefit is payable Yes

What’s Included in Extras Cover

Unless otherwise stated, benefit limits apply per person per calendar year.

Please also note that this page does not include the full detail of all services covered, and that sublimits apply for some services.  It is recommended that you either check your Online Member Services or contact us before your treatment to check exactly what you are covered what you are covered for.


Treatments Benefit (for commonly claimed items) Waiting Period
General Dental 011 – Periodic oral examination – $32.00
114 – Scale & clean – $55.20
121 – Fluoride treatment – $19.20
(Excluded: Sunglasses, where no sight correction is needed)
Single vision lenses & frames – $150.00
Multi-focal lenses & frames – $150.00
Frame – $80.00
Single Vision Lenses – $96.00
Multifocal Lenses – $150.00
Non PBS Pharmaceuticals (Excluded: contraceptives and items purchased over the counter) Per eligible prescription – $30.00  (Paid after General PBS copayment has been paid) $200
Chiropractic/Osteopathic Chiro/Osteo Initial visit – $32.00
Chiro/Osteo Subsequent visit – $24.00
Chiropractic X-rays – $80.00
Physiotherapy Physiotherapy Initial visit – $40.00
Physiotherapy Subsequent visit – $29.60

Important Hospital Information

For hospital services to which Phoenix Health Fund provides coverage, Top Hospital Essentials $500 Excess & Basic Extras provides coverage for:

  • Private and public hospital services nationwide (after the up-front excess has been paid) with access to an extensive range of quality services and approved programs in private hospitals which have an agreement with Phoenix Health Fund.
  • Public or Private Hospital bed – shared or private room (if available)
  • Same day patient fees
  • Theatre fees
  • Intensive care
  • Labour ward
  • In hospital pharmacy
  • Prosthesis (Commonwealth Government approved)
  • All other in-patient services where a Medicare benefit is payable (not listed as an exclusion in the hospital table above)

Additional costs you may incur are:

  • The amount the doctor charges above the Medicare schedule fee or “Access Gap” cover amount
  • some drugs, pharmacy items and non-PBS drugs for personal use or on discharge; and possibly
  • a co-payment for prostheses devices above the minimum benefit.
  • There are a small number of public hospitals that do not have agreements with us. In these cases a personal payment may apply.

Ambulance Coverage

Phoenix Health Fund covers all medically necessary transport from a State Emergency Ambulance service. This also includes when an Ambulance is called to attend to you, but you do not subsequently need to be taken to hospital. Coverage is not offered when it is not medically necessary for you to be transported by an Ambulance.

Excluded services

If you are to be admitted into a public or private hospital as an in-patient for an excluded service on your policy, the fund will not pay a benefit.

Restricted Services

If you are to be admitted into a public or private hospital as an in-patient for a restricted service, you will need to be aware of how your fund will pay your benefits.
Be aware that if you are admitted with a restricted service, significant out of pocket expenses can apply.

Service Category Benefit Rules
  • If you are admitted in a Public Hospital as a private patient, services will only be paid at the Public Hospital Shared Ward Accommodation rate
  • If you are admitted in a Private Hospital, accommodation benefits payable are in accordance with the relevant default benefits as determined by the Commonwealth Government, resulting in the member having a large out-of-pocket expense.
  • If you are admitted into a Private Hospital, no benefit for private hospital theatre fees, facility fees or labour ward apply.
  • If you are admitted into hospital, only Commonwealth Government approved prostheses will be covered.


If you are admitted to a hospital, you will pay an up-front excess of hospital costs until you have reached your excess maximum of $500 per person within a calendar year (1st January through to 31st December).

The excess is applied as follows:

  • The full $500 excess is payable on the first overnight admission (private or public hospital), and
  • A $250 up-front excess is payable on any day surgery admissions (private or public hospital).
  • Maximum excess per family membership is $1000.
  • Excess is waived for all dependent children on the Sole Parent or Family version of this policy.

Medical Gap cover


Phoenix Health Fund, as a member of the Australian Health Service Alliance, has “Access Gap” arrangements with more than 15,000 doctors Australia-wide. These arrangements minimise or eliminate Members’ out-of-pocket expenses when our Members are treated as admitted hospital patients.

If your doctor participates in the “Access Gap” scheme, you will either have no out-of-pocket expenses to pay or will know exactly how much you will have to pay before treatment begins. Your doctor can bill Phoenix Health Fund direct, so in most cases you will not be required to lodge a claim with us, making it easier for you.

To check whether your doctor participates in “Access Gap”, use our Doctor Search facility, or ask your doctor.

Top Hospital $500 Essentials Excess & Basic Extras waiting periods


  • 12 month waiting periods for pre-existing conditions
  • 2 month waiting periods for all other hospital items


  • 2 month waits for general dental and endodontic claims
  • 6 month waits for optical claims
  • Nil waiting periods for emergency ambulance
  • 2 month waits for all other extras item claims

Fund Rules

For the complete description of the Fund rules, relating this product, please refer to the General Information section on our website.

Please ensure you have read and retained the information relating to your policy of choice before applying for membership.