NHS prescription costs and how to pay less

Age exemptions are the broadest. Children under 16 pay nothing, 16 to 18 year olds in full-time education pay nothing, and anyone aged 60 or over pays nothing. These are checked against your date of birth on the prescription, but you still tick the box — the pharmacist does not apply it for you.

Pregnancy exempts you throughout and for 12 months after the birth, but not automatically. You need a maternity exemption certificate, applied for through your midwife, GP or health visitor. Applying late is the commonest reason women pay for prescriptions they did not owe, and the certificate can be backdated only a limited period.

The medical exemption certificate covers a defined list of conditions. It includes a permanent fistula requiring dressing, certain hormone deficiencies requiring replacement therapy such as hypothyroidism, diabetes treated with anything other than diet alone, hypoadrenalism, hypoparathyroidism, diabetes insipidus, myasthenia gravis, epilepsy requiring continuous anticonvulsant therapy, a continuing physical disability preventing you leaving home without help, and — added in 2009 — cancer, its effects, or the effects of its treatment.

That list is the 1968 list plus cancer. It reflects a specific historical moment: conditions where treatment was lifelong, replacement-based and unambiguous. It is why insulin-treated diabetes is exempt and asthma is not, why hypothyroidism is exempt and rheumatoid arthritis is not, and why serious mental illness requiring lifelong medication attracts no exemption at all. There is no clinical logic that makes this coherent today, and successive reviews have not changed it.

The certificate is applied for on form FP92A through your GP practice, lasts five years, and must be renewed. An expired certificate is one of the leading causes of penalty charge notices, because people carry on ticking the box.

Benefit-based exemptions cover Income Support, income-based Jobseeker's Allowance, income-related Employment and Support Allowance, Pension Credit Guarantee Credit, and certain tax credit awards. Universal Credit is the difficult one and is covered separately below, because it is where most wrong claims arise.

War pension exemption covers prescriptions for an accepted disablement, and there are exemptions for people held in prison or detained.

Receiving Universal Credit does not by itself exempt you from prescription charges. Exemption depends on your earnings in the assessment period covering the date of the prescription: broadly, you qualify if you had no earnings or earnings at or below a set threshold, with a higher threshold for a couple or where the award includes a child or limited capability for work element.

This means the same person can be exempt one month and not the next, on the same claim, depending on what they earned. It is the single most confusing rule in the whole system, and it produces enormous numbers of wrong claims made in complete good faith.

The NHS Business Services Authority checks exemption claims against benefit and certificate records after the event. Where a claim does not match, it issues a penalty charge notice for the original charge plus a penalty of up to five times that amount, with a further surcharge if it is not paid on time.

Receiving one is not the end of the matter. If you were in fact entitled — because a certificate existed, because the earnings in that assessment period were below the threshold, or because the check simply matched the wrong record — you can challenge it with evidence, and challenges succeed regularly. Do not pay a penalty you do not owe simply because the letter looks official.

The practical protection is to check before you tick. There is a free official eligibility checker that tells you whether you qualify for help with health costs, and using it takes a couple of minutes. If you are unsure at the counter, pay the charge and ask the pharmacist for an FP57 receipt, which lets you claim the money back within a time limit if it turns out you were exempt. Asking for the FP57 has to be done at the moment of payment — you cannot go back for one later.

The same penalty regime applies to dental charges and to optical vouchers, where the wrong-claim rate is also high.

A prescription prepayment certificate is a season ticket. You pay a fixed price and get unlimited prescription items for the period it covers, whatever they cost individually. There is a three-month version and a twelve-month version, and the twelve-month one can be paid by direct debit in instalments.

Work out whether it saves you money by counting items, not prescriptions. Divide the certificate price by the per-item charge to get the break-even number of items. If you regularly need more than that in the period, the certificate saves money — and the arithmetic works out at a small handful of items a month for the annual version.

Buy it online through the NHS Business Services Authority. You get the certificate number immediately, and you can start using it straight away by giving the number at the pharmacy before the physical certificate arrives.

You can backdate a certificate by a short period, which is useful if you have just had an expensive month. You can also claim back charges you paid in that window using FP57 receipts, provided you asked for them at the time.

It covers you regardless of how many different medicines, how many different conditions or how many different pharmacies. It does not cover dental treatment, wigs or fabric supports, which have their own charges.

One item worth checking separately: some very common medicines cost less over the counter than the prescription charge. Basic painkillers, antihistamines, some emollients and hayfever treatments frequently do. That does not mean you should stop asking your GP for them — for a long-term condition, having them on prescription keeps the medication record complete — but if you are paying per item and a pharmacist can sell you the same thing for less, ask.

Finally, if you have a prepayment certificate, remember to renew it. An expired certificate that you continue to rely on produces exactly the same penalty charge as a wrongly claimed exemption.

The Low Income Scheme is the safety net for people who are not on a qualifying benefit and have no exemption, but genuinely cannot afford health costs. It is means-tested on income, savings and outgoings including housing costs, and it is substantially under-claimed.

It produces one of two certificates. An HC2 gives full help — free prescriptions, free NHS dental treatment, free sight tests, help with glasses and travel costs to receive NHS treatment. An HC3 gives partial help, showing the maximum you have to pay towards each type of cost.

It covers more than prescriptions, which is why it matters even in Scotland, Wales and Northern Ireland where prescriptions are already free. Dental charges, optical vouchers and travel costs to hospital appointments are all within it, and dental treatment in particular is where the money is.

Students, pensioners on modest incomes above Pension Credit level, people with high housing costs, and self-employed people with variable income are the groups most likely to qualify and least likely to have heard of it.

Apply on form HC1, available from GP practices, pharmacies, hospitals, Jobcentre Plus and by post from the NHS Business Services Authority. It asks for detail on income, savings and outgoings, and the assessment takes a few weeks. Certificates run for a period and must be renewed.

If you live permanently in a care home and your fees are paid by the local authority, you should apply — a specific route exists and it produces full help in most cases.

You can claim back costs you have already paid while an application is being processed, using the receipts, so start the application rather than waiting until the next expensive month.

Some things carry no charge regardless of exemption status. Medicines given to you while you are an inpatient in hospital are free. Medicines administered at a hospital, GP practice or walk-in centre — an injection given to you rather than dispensed — are free. Contraceptives prescribed on the NHS are free. Medicines for a sexually transmitted infection prescribed at a specialist clinic are free. Medicines for tuberculosis and certain notifiable diseases are free on public health grounds.

Vaccinations given as part of a national programme are free, including seasonal flu vaccination for eligible groups, though the eligible groups change and vaccination for travel is generally charged.

Personally administered items given by a GP practice are free, which is why an injection at the surgery costs nothing while the same drug dispensed at a pharmacy attracts the charge.

Pharmacies do considerably more than dispense. Community pharmacists can now assess and treat a defined set of common conditions and supply prescription-only medicines for them without a GP appointment, under a scheme in England covering conditions including earache, sore throat, sinusitis, impetigo, shingles, infected insect bites and uncomplicated urinary tract infections in women. Where a prescription-only medicine is supplied this way the usual charge and exemptions apply, but the consultation is free and does not need an appointment.

Pharmacists will also review your repeat medication, tell you what can be bought more cheaply over the counter, and identify items you no longer need. A medicines review is free and is one of the more under-used services in primary care.

Order repeat prescriptions through the NHS App or your practice's online service rather than by phone or paper, and nominate a pharmacy so the prescription goes there electronically. It is faster, it removes the paper form as a point of failure, and it lets you see what has actually been issued.

If you are struggling with health costs generally, the NHS eligibility checker covers prescriptions, dental treatment, sight tests, glasses, wigs, fabric supports and travel to appointments in a single check. Most people who use it are checking one thing and find they qualify for help with another.