Education guide - Efficient Funding of Chemotherapy

Information about prescribing, dispensing and claiming pharmaceutical items under the Efficient Funding of Chemotherapy initiative.

Certain chemotherapy items which are administered by injection or infusion are available as pharmaceutical benefit items covered under the Efficient Funding of Chemotherapy initiative (EFC). These items are provided under Section 100 of the National Health Act 1953. They are listed in the Schedule of Pharmaceutical Benefits (the Schedule) under the following programs:

Program Available items
Chemotherapy items for private hospital and private clinic use Includes chemotherapy items administered through infusion or injection for use in a private hospital or clinic
Chemotherapy items for public hospital use Includes chemotherapy items administered through infusion or injection for use in a public hospital
Related pharmaceutical benefits for public hospital use Includes items such as antiemetics, antinauseants, immunostimulants and detoxifying agents for antineoplastic treatment for use in a public hospital

Patient eligibility

To be eligible a patient must:

  • be an Australian resident or other eligible person and hold a valid Medicare card, or
  • be eligible to be treated as a visitor from a country with which Australia has a Reciprocal Health Care Agreement. Supply is limited to the original prescription only. These patients cannot receive repeat prescriptions, and
  • meet the specific medical criteria for the item as listed in the Schedule

Steps for a prescriber

  1. The patient is referred to an authorised prescriber.
  2. The authorised prescriber determines chemotherapy protocol including administration by injection or infusion.
  3. The authorised prescriber writes a prescription for patient’s first infusion.

A prescription will be required for each infusion with an appropriate number of repeats as listed in the Schedule.

Steps for an approved supplier

  1. The prescription is received and entered into the pharmacy dispensing software, including the dose prescribed in the appropriate unit of measure as per the Schedule milligrams or micrograms.
    • The pharmacy dispensing software will return the vial combination to be dispensed
    • An algorithm integrated into the pharmacy dispensing software calculates the combination of vial sizes needed to make up the prescribed quantity into an infusion at the lowest cost
  2. The infusion is supplied and administered to the patient.
  3. The claim for payment is submitted to us.

Prescription requirements

All prescriptions must be written using Pharmaceutical Benefits Scheme (PBS) stationery. Public hospitals may dispense from approved medication charts where supply is within the public hospital. The following requirements apply to all EFC prescriptions:

  • prescribers must write dose specific prescriptions that specify the amount of active ingredients required for a single infusion or injection using milligrams or other relevant units of measure
  • the prescription will exclude reference to forms and strengths
  • prescribers can prescribe by brand but PBS claims will be calculated based on the most efficient combination of vial sizes available across all brands
  • when loading and maintenance doses differ, separate prescriptions are required
  • same day prescribing is allowed for chemotherapy items administered through infusion or injection only. Same day prescribing is not permitted for items listed as related pharmaceutical benefits
  • Regulation 24, where the original and repeat are supplied at the 1 time, and Regulation 25; the PBS 4/20 day rule will not apply to items under EFC
  • normal requirements for number of items per PBS prescription apply

EFC items are listed in the Schedule as:

  • Unrestricted – medicine that can be prescribed through the PBS or Repatriation Pharmaceutical Benefits Scheme (RPBS) without restrictions on therapeutic use
  • Restricted – medicine that can be prescribed through the PBS or RPBS only if the prescriber is satisfied that the patient’s clinical condition matches the therapeutic uses listed in the Schedule
  • Authority required – prescribers must obtain approval from us before prescribing these items
  • Authority required (STREAMLINED) – prior approval is not required, except where an increased amount and or number of repeats is required. However the prescription must include the 4-digit streamlined authority code

PBS Authority prescription

This image shows a sample of a completed PBS-RPBS authority prescription form. In the top left-hand corner is the prescriber’s name, address, phone number and PBS prescriber number. The top right hand corner shows the pre-printed authority prescription number. Below this is the patient’s Medicare number, name, and address. The item that has been prescribed in this sample is ‘Cetuximab’ shown in the centre of this prescription. The dosage directions read ‘Inject 300mg intravenously on day 1 week 1, and day 1 week 5’. An amount of 300mg and 1 repeat has been prescribed. The prescriber has signed and dated the prescription near the bottom right-hand corner. This prescription has been approved by us as shown by the phone approval number of ‘Z 1234 AB’ below the prescriber’s signature.

PBS public hospital prescription

This image shows a sample of a completed PBS-RPBS reformed public hospital prescription. In the top left-hand corner is the hospital name, address, phone number and provider number. This information along with the authority prescription number has been pre-printed on the prescription. This is followed by the patient’s Medicare number. In the top right hand corner, the patient’s details including the UR number, ward, name, address, and date of birth has been completed. The name of the item that has been prescribed in this sample is ‘Cetuximab’ shown in the centre of this prescription. The dosage directions read ‘Inject 300mg intravenously on day 1 week 1, and day 1 week 5’. An amount of 300mg and 1 repeat has been prescribed. This prescription includes the 4 digit Authority (STREAMLINED) code written by the prescriber. The prescriber has completed their name, contact details and PBS prescriber number on the bottom of this prescription followed by their signature and date.

Dispensing requirements

Each type of approved supplier is allocated a dispensing rule identifier that determines the dispensing rules that apply. Dispensing rules specify the fees and mark-ups that are payable.

Eligible suppliers include:

  • Section 90 pharmacists
  • Section 92 dispensing doctors
  • Section 94 participating public hospitals
  • Section 94 private hospitals
  • Section 94 non-participating hospitals but only for trastuzumab early-stage breast cancer

Prescriptions are written with specific doses. Pharmacists can dispense any subsidised brand or combination of brands. The most cost effective vial combination will be determined by the dispensing algorithm and it calculates the amount the approved supplier will be paid.

Example

An authorised prescriber prescribes 150 mg of a medicine that is available in vial sizes of 80 mg and 200 mg. The pharmacy dispensing software will use the algorithm to determine the most cost effective combination of vials. If the most cost effective option is 2 x 80 mg vials, then the pharmacist would be paid for 2 x 80 mg vials. If you are unable to dispense this combination, you are still able to use the 200 mg vial to prepare the item. However, you would only be paid for the cost of 2 x 80 mg vials.

Dose variations

It’s important to remember the following information about dose variations:

  • you do not need a new prescription if the
    • prescriber authorises the change verbally or in writing
    • dose varies no more than 10% from the original amount prescribed
    • dispensed dose is not 10% more than the maximum amount listed in the Schedule
  • you need a new prescription when the dose varies more than 10% from the original amount prescribed
  • doses on repeat prescriptions cannot vary more than 10% from the original amount prescribed
  • if a dose variation is needed, the pharmacist must endorse the prescription or medication chart with all of the following information
    • the name of the authorised prescriber who gave the direction
    • how the pharmacist was notified of the dose change; for example, by phone or fax
    • the date and time the pharmacist was notified
    • the dose the EFC prescription was varied to
    • the name of the pharmacist making the endorsement
    • the signature of the pharmacist making the endorsement

Patient costs

It’s important to remember the following information about patient costs:

  • standard PBS patient contributions are payable only on original prescriptions for each prescribed item. A patient contribution is not payable on repeat prescriptions
  • when loading and maintenance doses differ, separate prescriptions are required and attract 2 patient contributions
  • special patient contributions, therapeutic group premiums, and brand price premiums are applied to original and repeat prescriptions. Where an infusion consists of 3 vials where all attract premiums, the patient will be charged 3 premiums

Public hospital information

For public hospital patients to be eligible for EFC items they must be either:

  • receiving treatment from a participating public hospital and be a day admitted patient
  • a non-admitted patient, or
  • a patient on discharge

EFC items can be dispensed from public hospital medication charts when supply is within the public hospital.

EFC public hospital medication charts must also include the name and provider number of the hospital where the chart is prepared.

EFC public hospital prescriptions can be dispensed in a community pharmacy if:

  • the item is prescribed on an approved PBS hospital prescription – not a medication chart
  • it is prepared using the private hospital item code
  • the appropriate authority approval has been obtained by the prescriber, if applicable

Private hospital or private clinic prescriptions

Under the National Health Act 1953 a private hospital or private clinic EFC prescription cannot be dispensed and claimed by a Section 94 approved public hospital authority. Claim for payment for EFC items can be submitted to us through Online Claiming for PBS.

Claiming and remuneration

To be eligible for remuneration all claims for payment must include:

  • the drug item code. There are unique items codes for public hospital, and private hospital/private clinic items
  • the Authority required approval number or streamlined authority code, where applicable, and
  • the prescribed dose of the item

Remuneration for injectable and infusible EFC items recognises the specialist nature of chemotherapy preparation. There are different rates of remuneration depending on the approved supplier type. These are in addition to the ready prepared dispensing fees, are paid per item claimed and include:

  • the preparation fee
  • the distribution fee, and
  • the diluent fee

Infusions with more than a single eligible item will attract multiple fees. Where eligible this includes:

  • the preparation fee
  • the dispensing fee
  • the diluent fee
  • the distribution fee

Fees are indexed annually on 1 July. There are no wastage, container or dangerous drug fees payable.

Applicable fees per approved supplier type

Fee s. 90 Community Pharmacy (including s. 92 approved practitioners) s. 94 Approved Public Hospital Authority s. 94 Approved Private Hospital Authority
Distribution yes no yes (not payable where the item is trastuzumab
Diluent fee yes no yes
Preparation fee yes yes yes
Ready prepared dispensing fee yes no yes

More information

Contact us at PBS general enquiries and PBS authority telephone applications.

PBS website to view the Schedule.

Education services for health professionals to access other education resources.

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Page last updated: 4 July 2016

This information was printed Thursday 8 December 2016 from humanservices.gov.au/health-professionals/enablers/education-guide-efficient-funding-chemotherapy It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.