PBS for Pharmacists

Medicare can grant pharmacists approval to supply PBS subsidised medicine in accordance with section 90 of the National Health Act 1953.
From 1 April 2015, the way PBS and RPBS claims are processed is changing. Read more about the changes.

About

Becoming an approved PBS supplier – information for pharmacists

Information for pharmacists on becoming an approved supplier of PBS subsidised medicines.

Read more about becoming an approved PBS supplier for pharmacists

Annotating prescriptions to clarify a prescriber's intention

When something isn't clear on a Pharmaceutical Benefits Scheme (PBS) prescription, and getting a new prescription will delay the customer's treatment, you can call the prescriber to clarify their intentions. You may then annotate the prescription with the prescriber's intentions.

To clarify a prescription, you must:

  • call the prescriber first
  • clearly annotate and endorse the prescription with:
    • the date the prescriber was contacted
    • the prescriber's advice
    • your name and signature
  • keep a record of your discussion with the prescriber in your customer's dispensing history

Major changes to a prescription

If the prescription requires significant alterations or multiple changes, the patient will need to get a new prescription or an annotated prescription signed by the prescriber before you can supply and claim the medicine.

Changing an authority prescription

To change an authority prescription, you must contact the prescriber and annotate the prescription as above. The prescriber must also contact the PBS authority line to update the PBS authority approval record.

If the prescriber does not contact the PBS authority line, we will reject the claim.

Changes that will not be accepted

We will not pay the claim if changes are made to:

  • prescriptions for Schedule 8, Controlled Drugs medicines
  • supply a completely different medicine, for example, atenolol to metoprolol, or additional medicine, for example, prescription for atenolol only, changed to atenolol and fluoxetine
  • increase the quantity and/or repeats
  • the date of prescribing
  • supply the medicine to a different patient
  • the prescriber details
  • repeat forms

You can only change the repeat form to correct a previous pharmacist's dispensing error to make it consistent with the prescriber's original prescription.

Claiming

Online claiming for PBS

Information for pharmacists about electronic claiming of PBS or RPBS medicines with Medicare.

Read more about online claiming for PBS

Checking the systems status of Online Claiming for PBS

Check to see if there are system problems before transmitting online claims to us.

Our PBS system status tool can quickly show the availability and average response time of the Medicare eBusiness Services.

View the Online claiming for PBS system status tool.

Interpreting system status

Green

If the status is green you know that:

  • the Medicare's eBusiness Services are operating and
  • there is connectivity between your location and Medicare

In this case you should be able to transmit claims to us. If you are experience difficulties contact the PBS general enquiries line.

Red

If the status is red you know that:

  • Medicare's eBusiness Services are currently not operating and
  • there is connectivity between your location and Medicare

In this case you should wait 5 minutes and refresh the page. If the status is remains red you can a contact the PBS general enquiries line.

Ensuring timely payments when claiming PBS or RPBS

When making a claim for payment, you must make sure that each pharmaceutical benefit item claimed is supported by the relevant prescription documentation. The prescription documentation must be retained in electronic or paper form for a period of 2 years. Complete and accurate information in the PBS or RPBS claim will ensure that timely payments are made.

When entering data, make sure:

  • that the patient's PBS or RPBS eligibility is recorded correctly using the Medicare or repatriation card number and if applicable, concession or safety net card number
  • the correct prescriber number and date of prescribing are entered when dispensing
  • that for owing prescriptions, the date that the approved supplier telephoned the prescriber is the actual date of dispensing, rather than the date on the prescription form or the date the prescription was received

When closing a claim through your Prescription Dispensing Software, make sure:

  • you reconcile prescriptions in the actual prescription claim against the 'missing script' report
  • you delete prescription serial numbers from the computer claim corresponding to uncollected or missing prescriptions
  • you re-serialise prescriptions that are present but listed as missing
  • both the approval number and claim period number are valid
  • the certification of supply statement is completed by an authorised person
  • you use the 'Close a Claim' transaction to send the claim to the department for processing

Missing prescriptions or claim related paperwork for PBS claims

If your pharmacy has lost or damaged prescriptions or claim related paperwork due to circumstances outside of your reasonable control you can complete a statutory declaration that includes a statement about the lost or missing paperwork. Your declaration should include information about the nature of the loss, such as natural disaster, emergency or misplaced prescriptions.

If you are lodging a manual PBS claim, complete the Statutory Declaration form and send it to us along with your other prescriptions and claim paperwork. 

Example wording for your Statutory Declaration can be as follows:

  • I cannot provide the paper prescriptions to support this claim because of the effects of the disaster, e.g. a fire
  • I have not, and will not make a claim against my insurance company for the lost claim. If the prescriptions or claim paperwork is located I will forward it to the Department of Human Services with a note of explanation stating that I will not resubmit these prescriptions or claim paperwork for payment

A completed Statutory Declaration may be sent to:

Teams Manager
Pharmaceutical Benefits
Department of Human Services
GPO Box 9826 in your state

Read more about Statutory Declarations from the Attorney General's website.

Managing

Medicare Cards - Improved Monitoring of Entitlements

Improved Monitoring of Entitlements (IME) is a measure to ensure pharmaceutical benefits are provided only to those people eligible to receive them.

Read more about medicare cards - IME

The PBS concessional rate has not been applied

Information you can provide to your customers if they are not entitled to medicines at a concessional rate.

The Pharmacist is unable to charge you at the PBS Concessional rate

This is because:

  • Medicare's PBS online claiming system, which accesses data directly from Centrelink, indicates that your concessional entitlement is not current at this time, and/or
  • your entitlement card has expired

The pharmacist cannot charge you at the lower PBS concessional rate while you do not have a valid concessional entitlement.

Before pharmacies can give you Pharmaceutical Benefits Scheme (PBS) or Repatriation Pharmaceutical Benefits Scheme (RPBS) medicine at a subsidised rate, they are required by law to check your entitlement status to ensure they are valid. This is an Australian Government requirement that ensures only eligible people receive subsidised PBS/RPBS medicine, helping to ensure that the PBS remains sustainable for all Australians.

Invalid cards

There could be several reasons why a card is invalid, including:

  • your card has expired
  • you may have recently changed your name
  • your Centrelink payments have stopped
  • you have returned from overseas and have not informed Centrelink
  • there have been changes in the caring arrangements of your children
  • there have been changes in you income
  • there have been changes in the living arrangements of either you or your partner

If you are unsure of why you are not entitled, and you would like to query this matter, you should contact the government agency that issued the card.

Government agencyType of CardContact us
Medicare
  • Medicare Card
  • PBS Safety Net Entitlement Card
Centrelink
  • Pensioner Concession Card
  • Commonwealth Seniors Health Card
  • Health Care Card
Department of Veterans' Affairs (DVA)

Repatriation Health Cards:

  • Gold, White or Orange card
  • Pensioner Concession Card
  • Commonwealth Seniors Health Card

The customer service officer will be able to provide you with further information.

If you pay a higher price for your prescription and it is found that you were actually entitled when you were supplied the medicine, then you will be able to claim a refund at a Medicare or Department of Veterans' Affairs (DVA) office, once you have shown:

  • the receipt for the medicine
  • your valid entitlement card(s)

Pharmacies check entitlement cards

Under the PBS, our taxes subsidise the cost of prescription medicine making it more affordable for all Australians. The cost of some medicine is much more than the price you pay – in some cases hundreds of dollars more – but our taxes provide eligible people a subsidy so they pay less.

Deactivation of PBS pharmacist approvals

Pharmacists who wish to temporarily 'deactivate' an approval to supply pharmaceutical benefits.

Read more about deactivation of PBS pharmacist approvals

Resources

PBS reason codes for online claiming for PBS Pharmacies

PBS claims processing reason codes for online claiming for PBS pharmacies.

Read more about PBS reason codes for online claiming for PBS Pharmacies

Collection of under co-payment prescription data

The National Health Act 1953 requires approved suppliers to supply prescription data for items that are priced below the patient co-payment to us. This data provides us with information about medicine use in the community and is a valuable tool for:

  • health policy planning
  • monitoring risk management protocols
  • collecting information on the adverse effects of medicines
  • monitoring the quality use of medicines in the community

Under co-payment prescription data is collected through the Online Claiming for Pharmaceutical Benefits Scheme (PBS) channel through Pharmacy Dispensing Software.

PBS systems assess under co-payment data and only a limited set of reject reason codes will be returned for approved suppliers for follow up.

Pricing of Pharmaceutical Benefits Scheme medicine

Detailed information on how prescription medicine are priced under the PBS and RPBS.

Read more about the pricing of Pharmaceutical Benefits Scheme medicine

PBS reforms 2006 and 2008

In November 2006, a package of reforms to the Pharmaceutical Benefits Scheme (PBS) was announced by the Australian Government. A complete overview of the PBS reforms can be found on the Department of Health website.

Premium free dispensing incentive

Since 1 August 2008, an incentive payment, which was indexed to $1.56 as of 1 August 2010 has been paid to all Friendly Societies and community pharmacies (section 90), dispensing doctors (section 92) and hospitals (section 94, not public hospitals participating in the pharmaceutical reforms in public hospitals) that dispense a subsidised PBS medicine, which costs the patient no more than the standard patient contribution.

The incentive supports the dispensing of premium free PBS-listed products in cases where there are multiple, substitutable versions of an item on the PBS. It also ensures customers are aware of their right to pay no more than the patient contribution for their medicine and encourages greater use of generic medicine.

For a pharmacy to receive the premium free dispensing incentive, they must identify the brand dispensed in their claim to us.

Payment of the incentive is made at the same time that a pharmacy claim is assessed and paid by us.

The premium free dispensing incentive is separately identified on the Medicare reconciliation statements. The statements display the total number of prescriptions paid, the amount paid, and also identify individual prescriptions that were paid the online claiming incentive.

Streamlined authority process

The Pharmaceutical Benefits Schedule (the Schedule) now identifies certain items as 'authority required (streamlined)'. Prescriptions for listed quantities or repeats for these items no longer require telephone approval from us or the Department of Veterans' Affairs to obtain an authority approval number.

Prescribers can find the streamlined authority code in the Schedule next to the text that describes the indications for which the item may be prescribed.

Placement of authority approval number on prescriptions

Prescribers will still need to place the authority approval number on prescriptions to show that the prescription meets agreed prescribing requirements. No changes have been made to requirements about the placement of this number or any other information on the script. The streamlined authority code will be published next to the appropriate indication in the Schedule.

Department of Veterans' Affairs approval process

Some authority required items are listed in both the PBS and Repatriation Pharmaceutical Benefits Scheme (RPBS) sections of the Schedule of Pharmaceutical Benefits, for example, clopidogrel. There are no authority required (streamlined) items listed in the RPBS Schedule.

RPBS prescriptions can be written with a streamlined authority code. This is because veterans can be prescribed any item in the general section of the Schedule - including authority required (streamlined) items - as long as they meet the relevant requirements.

RPBS prescriptions that have been endorsed with a streamlined authority code can be dispensed with the relevant PBS streamlined authority item code as specified on the prescription.

Increased quantities and repeats

When a prescriber wants to increase quantities or repeats, prior authority must be sought from either us or the Department of Veterans' Affairs. The streamlined authority process will not apply in these circumstances.

Revised arrangements for the efficient funding of chemotherapy medicines

Revised arrangements for prescribers and pharmacists aim to minimise waste and reduce expenditure on intravenous chemotherapy medicines.

An initiative has been introduced to minimise waste and reduce Pharmaceutical Benefits Scheme (PBS) expenditure on chemotherapy medicines used in the treatment of cancer and administered through intravenous infusion or injection.

This has changed the PBS and led to new remuneration arrangements.

Revised arrangements for prescribers

For health professionals who prescribe chemotherapy medicines:

  • prescriptions will need to be dose-specific and written in milligrams or other unit of measure as appropriate
  • patients will generally pay no more than 1 co-payment per cycle of treatment, for example a co-payment will be paid on each original prescription, but not on each repeat
  • 1 prescription is required, either an original or repeat if needed per infusion or injection

The number of repeats on the prescription must be clinically appropriate for the treatment protocol that the patient is undergoing and within the parameters set by the Pharmaceutical Benefits Advisory Committee (PBAC). If additional repeats are required, an authority will need to be sought.

Revised arrangements for pharmacies

For approved pharmacies that dispense chemotherapy medicines:

  • pharmacies will only be paid for the most cost-efficient combination of vials that make up a patient's dose, and
  • the specialist nature of preparing chemotherapy medicines will be acknowledged with a series of new dispensing fees depending on where the medicines are claimed

These fees include:

  • distribution fee
  • diluent fee
  • preparation fee
  • dispensing fee
  • the revised arrangements have been implemented under a new section 100 special arrangement

All medicine that meets the criteria for inclusion in the measure, including trastuzumab (Herceptin®), is subject to the new prescribing, dispensing and claiming arrangements.

Average rates payable for extemporaneous items

A table of the average 10 g/ml rates payable for extemporaneous items supplied. These rates apply to extemporaneously-prepared benefits not included in the Standard Formulae List.

Read more about average rates payable for extemporaneous items

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