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SIRA Pharmacy Codes Decoded
A practical reference for claims managers and case coordinators on SIRA pharmacy billing codes — what they mean, which medications they cover, and when to refer for an independent Pharmacy Review.
About SIRA Pharmacy Codes
Why These Codes Matter for Claims
SIRA pharmacy billing codes classify medications dispensed to injured workers and CTP claimants. The code group tells you the risk category immediately — and high-risk codes are where independent clinical review adds the most value.
High-Risk Codes (PHS100–PHS230)
Opioids, benzodiazepines, and Z-drugs. These categories carry the highest risk of dependency, functional impairment, and claim escalation. Mandatory review under most insurer frameworks.
Specialist Code (PHS300)
Medicinal cannabis. All cannabinoid products receive this code regardless of schedule or formulation. SAS or Authorised Prescriber documentation should be confirmed.
Other Medications (PHS400–PHS430)
All medications not falling into the above groups — from antidepressants and antipsychotics to NSAIDs and OTC items. Still reviewable when clinical rationale is unclear.
How to Read a SIRA Pharmacy Code
Each code encodes two pieces of information: the drug category (first digit group) and the supply channel (PBS, Private, or non-PBS).
Opioids
The highest-risk category in the SIRA pharmacy schedule. Opioids are appropriate for acute pain management but carry significant risks in the long-term claims context — including dependency, functional impairment, and increased claim duration and cost.
Example Medications
Opioids dispensed under PBS subsidy. Will show a PBS item number on the invoice. Dose, duration, and prescriber speciality should all be reviewed on any complex claim.
Example Medications
Private dispensing of opioids is common when the patient has exceeded PBS quantities, or when the prescription is for a non-PBS indication. Often a prompt to investigate quantity and clinical justification.
Example Medications
Non-PBS opioids often have limited clinical evidence for the specific formulation or indication. A strong flag for independent review of clinical rationale and claim relatedness.
Example Medications
Injectable opioids are highest acuity. Typically associated with hospital or palliative care settings. Presence in a workers comp claim requires immediate clinical review.
Example Medications
Medication Assisted Treatment for Opioid Dependence. Presence on a claim does not preclude work injury funding, but requires nuanced clinical review — dependency may be iatrogenic (caused by prescribed opioids for the injury).
🔴 Red Flags — When to Refer for a Pharmacy Review
- Opioid prescribed beyond 3 months for a musculoskeletal injury without specialist review
- Multiple opioids prescribed concurrently (opioid polypharmacy)
- Opioid combined with benzodiazepine or Z-drug — significantly elevated overdose risk
- Dose escalation without documented clinical review
- PHS130 (injectable) appearing outside a hospital admission context
- MATOD medications (PHS140) without clear link to accepted injury treatment
- SafeScript NSW RTPM check recommended for all Schedule 8 opioids
Benzodiazepines
Prescribed for anxiety, muscle spasm, and sleep. In the claims context, long-term benzodiazepine use raises significant concerns around dependency, cognitive impairment, functional capacity, and return-to-work readiness.
Example Medications
PBS-subsidised benzodiazepines. Alprazolam and clonazepam carry particularly high dependency risk. All are Schedule 8 in NSW when prescribed for >8 weeks — RTPM check applies.
Example Medications
Private dispensing of benzodiazepines often signals that prescribing exceeds PBS-permitted quantities — a strong clinical red flag. Review prescribing frequency and quantity against clinical need.
Example Medications
Non-PBS benzodiazepines are uncommon and warrant scrutiny regarding clinical necessity, especially in the absence of a specialist prescriber.
⚠️ Key Considerations for Benzodiazepine Claims
- Guidelines recommend benzodiazepines for no more than 2–4 weeks; any long-term use requires clinical justification
- Combined opioid + benzodiazepine prescribing represents a critical polymedication risk — escalate immediately
- Alprazolam and clonazepam are not first-line recommended agents and carry higher abuse potential
- Cognitive effects may be relevant to capacity assessments and return-to-work suitability
- RTPM check via SafeScript NSW recommended for all S8 benzodiazepines prescribed beyond 8 weeks
Z-Drugs and Anxiolytic / Sleep Medications
Non-benzodiazepine sleep and anxiety medications. Grouped separately from benzos but carry overlapping risks — particularly for sedation, dependency, and next-day cognitive impairment relevant to occupational function.
Example Medications
Z-drugs and off-label anxiolytics. Note that pregabalin and quetiapine may appear here when prescribed primarily for sleep or anxiety rather than their primary indication — context matters for claim relatedness assessment.
⚠️ Z-Drug and Anxiolytic Considerations
- Zolpidem and zopiclone are Schedule 4 but have recognised dependency and tolerance risk with chronic use
- Pregabalin has significant misuse potential and is often prescribed off-label — confirm accepted injury relatedness
- Low-dose quetiapine for sleep is off-label use with metabolic and sedation risks — review clinical rationale
- Any PHS230 medication combined with PHS100 or PHS200 codes represents a high-risk polymedication combination
Medicinal Cannabis
All medicinal cannabis products — including over-the-counter cannabidiol (CBD) preparations — must be coded PHS300 regardless of schedule, formulation, or prescribing pathway. This code captures the full spectrum of cannabinoid therapies.
Example Products and Pathways
Medicinal cannabis prescribed via the SAS-B pathway requires TGA approval per patient. Authorised Prescriber pathway allows ongoing prescribing without per-patient TGA approval. Evidence for workers compensation injury indications is variable across conditions.
⚠️ Medicinal Cannabis in Claims
- High cost per item — typically $150–$500+ per dispensing event
- THC-containing products are Schedule 8 and carry impairment risks relevant to return-to-work
- Evidence base for pain indications is moderate; evidence for anxiety, PTSD, and sleep is mixed
- Driving restrictions apply to products containing THC — consider functional capacity implications
- Confirm prescribing doctor holds TGA authorisation before approving ongoing funding
All Other Medications
Any medication not classified as an opioid, benzodiazepine, Z-drug, or medicinal cannabis falls into this group. This is a broad and heterogeneous category — from antidepressants and antipsychotics to anti-inflammatories and over-the-counter preparations.
Commonly Includes
PBS-subsidised medications outside high-risk categories. Still may require Pharmacy Review when claim relatedness is unclear or when the medication profile suggests a complex presentation.
Commonly Includes
Private dispensing of standard medications may indicate off-label use, non-standard doses, or PBS restrictions being circumvented. Review clinical justification when costs are elevated.
Commonly Includes
Non-PBS private medications can represent significant cost and may lack robust evidence. Review appropriateness and claim relatedness before approving ongoing supply, particularly for compounded preparations.
Commonly Includes
OTC medications related to the accepted injury are reimbursable. Items that are general health products (supplements, vitamins, non-injury-related OTC items) should be excluded. The invoice should clearly link the product to the injury.
⚠️ When PHS400-Series Medications Warrant Review
- Medication appears inconsistent with the accepted injury (e.g. dementia medications on a musculoskeletal claim)
- Antipsychotics or mood stabilisers appearing without a corresponding psychological injury acceptance
- Dexamphetamine or stimulant medications — confirm PBS authority and accepted condition context
- Multiple psychotropic medications indicating complex polypharmacy requiring clinical oversight
- High-cost compounded or imported preparations (PHS420) without clear clinical evidence
Quick Coding Decision Guide
When reviewing a pharmacy invoice, step through this hierarchy to assign the correct PHS code.
Quick Reference
All SIRA Pharmacy Codes at a Glance
Source: SIRA NSW medication coding guidance and icare Workers Care payment codes schedule.
| Code | Description | Common Medications | Risk Level |
|---|---|---|---|
| PHS100 | Opioids — PBS | Oxycodone, morphine, fentanyl patch, tapentadol, hydromorphone | Critical |
| PHS110 | Opioids — Private | Same as PHS100, privately dispensed | Critical |
| PHS120 | Opioids — Not on PBS | Non-PBS opioid formulations, compounded opioids | Critical |
| PHS130 | Opioids — Injectable | Morphine injection, hydromorphone injection, pethidine | Critical |
| PHS140 | MATOD (Opioid Dependency) | Methadone, buprenorphine/naloxone (Suboxone), Sublocade | Critical |
| PHS200 | Benzodiazepines — PBS | Diazepam, temazepam, oxazepam, clonazepam, alprazolam | High |
| PHS210 | Benzodiazepines — Private | Same as PHS200, privately dispensed | High |
| PHS220 | Benzodiazepines — Not on PBS | Non-PBS benzodiazepine formulations | High |
| PHS230 | Z-Drugs / Anxiolytic & Sleep | Zolpidem, zopiclone, pregabalin (anxiety), quetiapine (sleep use) | High |
| PHS300 | Medicinal Cannabis | All cannabinoid products — THC, CBD, combination formulations, OTC CBD | Review |
| PHS400 | Other Medications — PBS | SSRIs, SNRIs, antipsychotics, anticonvulsants, NSAIDs, muscle relaxants | Standard |
| PHS410 | Other Medications — Private | As PHS400 dispensed privately; off-label scripts | Standard |
| PHS420 | Other Medications — Non-PBS | Compounded preparations, imported medications, specialty biologics | Standard |
| PHS430 | Over-the-Counter Medications | Paracetamol, ibuprofen (OTC), topical analgesics, wound care | Standard |
Uncertain About a Pharmacy Invoice?
If a medication on a claim doesn't make clinical sense — or if you're seeing a combination of high-risk codes — IMM's pharmacists can provide an independent clinical opinion through a Pharmacy Review.
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