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.

Legislation supporting Improved Monitoring of Entitlements (IME) is known as the National Health Amendment (Improved Monitoring of Entitlement of Pharmaceutical Benefits) Act 2000. It came into full effect on 1 May 2002.

Payments to pharmacists in relation to the dispensing of prescriptions for pharmaceutical benefits is dependent on:

  • the pharmacist providing the patient's Medicare card number or Veterans' Affairs file number with their claim, and
  • the Medicare card number, where used, matching the one held by us in relation to that particular person

IME is a measure to ensure pharmaceutical benefits are provided only to those people eligible to receive them.

IME does not change patient entitlements.

A patient's Medicare number or Veterans' Affairs file number and concession card number if applicable has to be included on pharmaceutical benefit prescription information provided to us. This ensures that when a PBS claim is made, the claimant can be reliably identified and their eligibility checked by us.

Benefits

This measure will help ensure taxpayers' dollars go to those people who are entitled to them. The IME checks entitlement arrangements and reduces the number of subsidies paid to ineligible people, for example, visitors from countries without a Reciprocal Health Care Agreement and illegal immigrants.

Providing proof of eligibility

Most people only need to provide their Medicare card number to the pharmacist when having prescriptions filled for medicines listed under the PBS.

In order to receive an additional subsidy, concession card holders are also required to provide their concession card number.

Veterans covered by the Repatriation Pharmaceutical Benefits Scheme (RPBS) need to provide their Veteran's Affairs file number which is their Gold, White or Orange card.

White card holders are required to provide their Medicare card number for prescriptions not covered under the RPBS.

People collecting prescribed medicines for someone else must provide proof of that person's eligibility to the pharmacist.

Visitors to Australia

People from countries with a Reciprocal Health Care Agreement who have not been issued with a Medicare card, should show their passport to the pharmacist when having prescriptions filled.

Customers without a Medicare card number

A customer can obtain the Medicare card number by:

A customer may pay full price for their medication and if they are eligible, they may be able to obtain a refund from a Medicare office or DVA state office. The customer will require a PBS patient refund receipt from the pharmacy.

Medicare special numbers

In some circumstances, people who are entitled to receive pharmaceutical benefits may not be able to provide a Medicare number. Special numbers have been established to cover emergencies and other situations where consumers are eligible but cannot produce a Medicare card number. The legislation to support the use of Medicare special numbers is outlined in the National Health (Entitlement to Pharmaceutical Benefits – Special Evidentiary Categories) Determination 2001.

The pharmacist may use one of the special numbers if the circumstances fit. There are 6 Medicare special numbers available for pharmacists to use in these circumstances.

Medicare special numbers are designed to be used when eligible people are unable to produce a Medicare card such as some Indigenous Australians and eligible overseas visitors.

We encourage a culture of voluntary compliance with the programs we administer. We will monitor the use of Medicare special numbers and, where appropriate, conduct audits to verify appropriate use.

It is the responsibility of pharmacists to make sure Medicare special numbers are used appropriately.

The Medicare special numbers available for pharmacists to use in their PBS claim are listed below.

Medicare special number Explanation and use
25437754111 Emergency situation
25437759611 Visitors covered by a Reciprocal Health Care Agreement (RHCA)
25437766611 People a doctor considers are entitled to PBS
25437768411 People a pharmacist considers are entitled to PBS
25437529911 Urgent clinical need
25437783311 Seemingly valid Medicare card form

Obtaining the numbers

We provide a service to assist pharmacists in obtaining Medicare or Veteran's card numbers for use in Pharmaceutical Benefits Scheme (PBS) claims.

A maximum of 5 numbers and expiry dates can be released per call.

Call PBS general enquiries with the consent of the patient, to obtain the patient's Medicare or Veteran's card number and card expiry date.

Page last updated: 13 October 2016

This information was printed Thursday 8 December 2016 from humanservices.gov.au/health-professionals/enablers/medicare-cards-improved-monitoring-entitlements 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.