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Why These Codes Matter for Claims
SIRA pharmacy billing codes classify medications dispensed to injured workers and CTP claimants in NSW. The code group on a pharmacy invoice tells you the risk category immediately, and high-risk codes are where independent clinical review adds the most value to a claim.
For claims managers, knowing the four parent code groups (PHS100, PHS200, PHS300, PHS400) is enough to triage almost every pharmacy line item that crosses your desk.
SIRA pharmacy codes are not just billing artefacts. The first digit after PHS tells you the drug category (opioid, benzo, cannabis, or other) and the trailing digits tell you the supply channel (PBS, Private, Non-PBS, or Specialty). A code like PHS210 immediately tells you: privately dispensed benzodiazepine, and that should trigger a closer look.
How to Read a SIRA Pharmacy Code
Each SIRA pharmacy code encodes two pieces of information: the drug category and the supply channel. Reading them in that order is the fastest way to triage an invoice.
Step 1: Identify the parent group
The first digit after PHS tells you the drug category. PHS1xx is opioids, PHS2xx is benzodiazepines and z-drugs, PHS3xx is medicinal cannabis, and PHS4xx is everything else.
Step 2: Identify the supply channel
The trailing digits indicate PBS (00), Private (10), Non-PBS (20), or a specialty subcategory (30 or 40). Private and Non-PBS dispensing often signals that PBS quantities have been exceeded, or that the medication is being used outside its standard indication.
Step 3: Match to risk tier
Codes PHS100 to PHS230 are high-risk and warrant routine review. PHS300 is a specialist code that requires confirmation of TGA authorisation. PHS400 to PHS430 are standard, but still reviewable when clinical rationale is unclear.
Opioids (PHS100 to PHS140)
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.
| Code | Description | Example medications | Risk flag |
|---|---|---|---|
| PHS100 | Opioids, PBS | Oxycodone (OxyContin, Endone), morphine (MS Contin, Kapanol), tapentadol (Palexia), fentanyl patch (Durogesic), hydromorphone (Jurnista), buprenorphine patch (Norspan), tramadol (Tramal), codeine 30mg or higher | Critical |
| PHS110 | Opioids, Private | Same agents as PHS100 dispensed without PBS subsidy. Often signals PBS quantity caps exceeded. | Critical |
| PHS120 | Opioids, Not on PBS | Pethidine, some modified-release formulations, imported or compounded opioids. | Critical |
| PHS130 | Injectable opioids | Morphine injection, hydromorphone injection, oxycodone injection, pethidine injection. | Critical |
| PHS140 | MATOD (opioid dependency) | Methadone (Biodone, Physeptone), buprenorphine/naloxone (Suboxone), buprenorphine (Sublocade monthly injection, Subutex). | Critical |
Refer for a Pharmacy Review when an opioid has been prescribed beyond 3 months for a musculoskeletal injury without specialist input, when multiple opioids are dispensed concurrently, when an opioid is combined with a benzodiazepine or z-drug, when doses escalate without documented review, when PHS130 appears outside a hospital admission, or when MATOD codes appear without a clear link to the accepted injury. SafeScript NSW RTPM check is recommended for all Schedule 8 opioids.
Benzodiazepines and Z-Drugs (PHS200 to PHS230)
Prescribed for anxiety, muscle spasm, and sleep. In the claims context, long-term benzodiazepine and z-drug use raises significant concerns around dependency, cognitive impairment, functional capacity, and return-to-work readiness.
Benzodiazepines (PHS200 to PHS220)
| Code | Description | Example medications | Risk flag |
|---|---|---|---|
| PHS200 | Benzodiazepines, PBS | Diazepam (Valium), oxazepam (Serepax), temazepam (Normison), nitrazepam (Mogadon), lorazepam (Ativan), clonazepam (Rivotril), alprazolam (Xanax). | High |
| PHS210 | Benzodiazepines, Private | Same agents as PHS200 dispensed privately. Often a strong signal that PBS quantity limits have been exceeded. | High |
| PHS220 | Benzodiazepines, Not on PBS | Non-PBS benzodiazepine formulations, higher-dose preparations, imported or compounded products. | High |
Z-Drugs (PHS230)
PHS230 is reserved for z-drugs only: zolpidem (Stilnox), zopiclone (Imovane), zaleplon, and eszopiclone. Despite popular usage, pregabalin, gabapentin, quetiapine, and mirtazapine do not belong under PHS230. They are coded under the PHS400 series even when prescribed off-label for sleep or anxiety.
Clinical guidelines recommend benzodiazepines for no more than 2 to 4 weeks. Any longer-term use needs a documented rationale. The combination of an opioid plus a benzodiazepine is a critical polymedication risk and should be escalated immediately. Alprazolam and clonazepam are not first-line agents and carry higher abuse potential. Cognitive and next-day sedation effects from z-drugs may be directly relevant to capacity assessments and return-to-work suitability.
Medicinal Cannabis (PHS300)
All medicinal cannabis products, including over-the-counter cannabidiol (CBD) preparations, must be coded PHS300 regardless of schedule, formulation, or prescribing pathway. PHS300 is the only specialist single-code group in the SIRA schedule.
| Code | Description | Example products and pathways | Risk flag |
|---|---|---|---|
| PHS300 | Medicinal cannabis, all products | THC-dominant oil or capsule (Schedule 8), CBD-dominant oil (Schedule 4), balanced THC:CBD products, dried flower for vaporisation, OTC CBD (pharmacist-only). SAS-B or Authorised Prescriber pathway. | Requires review |
Look for a TGA approval letter (SAS-B) or confirmation of Authorised Prescriber status. Claim relatedness should be assessed against accepted conditions. Evidence for chronic pain is moderate, while evidence for anxiety, PTSD, and sleep remains mixed. THC-containing products carry impairment and driving restrictions that may shape return-to-work planning.
Cost per dispense is typically in the $150 to $500-plus range, so the cumulative claim exposure adds up quickly. Confirm the prescribing doctor holds appropriate TGA authorisation before approving ongoing funding, and ensure the indication aligns with the accepted injury.
All Other Medications (PHS400 to PHS430)
Any medication not classified as an opioid, benzodiazepine, z-drug, or medicinal cannabis falls into this group. It is a broad and heterogeneous category covering antidepressants, antipsychotics, anticonvulsants, NSAIDs, muscle relaxants, ADHD stimulants, and over-the-counter items.
| Code | Description | Example medications | Risk flag |
|---|---|---|---|
| PHS400 | Other medications, PBS | SSRIs and SNRIs (sertraline, venlafaxine, duloxetine), antipsychotics (quetiapine, olanzapine, risperidone), anticonvulsants (pregabalin, gabapentin, valproate), muscle relaxants (baclofen, tizanidine), NSAIDs (celecoxib, meloxicam), topical analgesics, PPIs, dexamphetamine and lisdexamfetamine. | Standard |
| PHS410 | Other medications, Private | As PHS400, dispensed privately. Often indicates off-label prescriptions or non-PBS doses. | Standard |
| PHS420 | Other medications, Not on PBS | Compounded preparations, imported medications, specialty biologics, niche or experimental treatments. | Standard |
| PHS430 | Over-the-counter medications | Paracetamol (Panadol, Panamax), ibuprofen (Nurofen, OTC dose), topical anti-inflammatory gels, low-dose aspirin, antihistamines, wound care products. | Standard |
Standard does not mean automatic approval. Review when the medication appears inconsistent with the accepted injury (for example, dementia medications on a musculoskeletal claim), when antipsychotics or mood stabilisers appear without a corresponding psychological injury acceptance, when stimulant medications appear without confirmed PBS authority, when multiple psychotropics indicate complex polypharmacy, or when high-cost compounded or imported preparations under PHS420 lack robust clinical evidence.
Quick Coding Decision Guide
When reviewing a pharmacy invoice, step through this hierarchy to assign the correct PHS code group.
Step 1: Is it a medicinal cannabis product?
If yes, code PHS300, regardless of schedule, formulation, or prescribing pathway. This includes OTC CBD.
Step 2: Is it an opioid?
Determine whether it is for pain relief (PHS100 PBS, PHS110 Private, or PHS120 Non-PBS), injectable (PHS130), or for opioid dependency treatment (PHS140).
Step 3: Is it a benzodiazepine?
Diazepam, temazepam, alprazolam, clonazepam, oxazepam, lorazepam, or nitrazepam. Then determine supply channel: PHS200 PBS, PHS210 Private, or PHS220 Non-PBS.
Step 4: Is it a z-drug?
Zolpidem, zopiclone, zaleplon, or eszopiclone only. Code PHS230. Pregabalin, gabapentin, quetiapine, and mirtazapine do not belong here, even when used off-label for sleep.
Step 5: Everything else
Use the PHS400 series. Choose PHS400 (PBS), PHS410 (Private), PHS420 (Non-PBS), or PHS430 (OTC) based on supply channel.
All SIRA Pharmacy Codes at a Glance
Source: SIRA NSW medication coding guidance and icare Workers Care payment codes schedule. Verify all current listings against published sources before applying to a specific claim.
| 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, 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 only | Zolpidem, zopiclone, zaleplon, eszopiclone | High |
| PHS300 | Medicinal cannabis | All cannabinoid products: THC, CBD, combinations, 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 | Paracetamol, ibuprofen (OTC), topical analgesics, wound care | Standard |
When to Refer a Claim for Pharmacy Review
If a medication on a claim does not make clinical sense, or if you are seeing a combination of high-risk codes, an independent pharmacy review is the fastest way to get clarity. Independent Med Management (IMM) pharmacists routinely review pharmacy invoices for NSW workers compensation and CTP insurers.
Refer when you see:
- Concurrent PHS100 and PHS200 codes (opioid plus benzodiazepine combination)
- Multiple PHS100-series codes (opioid polypharmacy)
- PHS140 (MATOD) appearing where the link to the accepted injury is unclear
- PHS300 (medicinal cannabis) without documented TGA authorisation
- PHS420 high-cost compounded preparations without clear clinical evidence
- Antipsychotics or stimulants on PHS400 without a corresponding psychological injury acceptance
IMM provides an average 8-day turnaround on pharmacy reviews, with an 81% prescriber implementation rate. Submit a referral via the IMM referral form or speak to the clinical team for case-specific guidance.
