PBS for pharmacists
Medicare can grant pharmacists approval to supply Pharmaceutical Benefits Scheme (PBS) subsidised items in accordance with section 90 of the National Health Act 1953.
Since 1 January 2016, community pharmacies and dispensing medical practitioners have had the option to discount up to a maximum of $1.00:
- the general PBS patient co-payment, and
- the concessional PBS patient co-payment
Patients will still need to make a co-payment for each original and repeat prescription. This applies to medicines with a Commonwealth price equal to or above the co-payment as per current PBS Safety Net provisions.
You can discount the co-payment for:
- prescriptions endorsed with ‘Regulation 24’ or ‘Hardship conditions apply’, and
- Closing the Gap (CTG) prescriptions
You must record the co-payment amounts for these prescriptions on the Prescription Record Form.
You can supply a pharmaceutical benefit under Regulation 25 if the prescriber has indicated an immediate supply is necessary. In this situation, as part of the PBS Safety Net 20 day rule, you can only discount the co-payment by up to $1.00 if the supply is for a medicine not specified in the early supply instrument.
For more information go to Department of Health’s website.
Information for pharmacists on becoming an approved supplier of PBS subsidised items.
When something isn't clear on a 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:
- first call the prescriber
- 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 item.
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 or go online to update the PBS authority approval record.
If the prescriber does not contact the PBS authority line, we will reject the claim.
Read more about PBS authorities
Changes that will not be accepted
We will not pay the claim if:
- changes were made to prescriptions for Schedule 8, Controlled Drugs items
- a completely different item was supplied - for example, atenolol to metoprolol, or additional item; or, for example, a prescription for atenolol only changed to atenolol and fluoxetine
- changes were made to increase the quantity and/or repeats
- changes were made to the date of prescribing
- the item was supplied to a different patient
- changes were made to the prescriber details
- changes were made to 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.
A patient can only receive one supply of eligible medicine every 12 months.
‘Continued dispensing’ is regulated by the National Health Act 1953. It is the responsibility of pharmacists in each state or territory to make sure the necessary legislation is enacted in their place of practice before undertaking a continued dispensing supply.
Schedule 1 of the National Health (Continued Dispensing) Determination 2012 (Commonwealth) lists medicines that are eligible for continued dispensing.
For more information on the continued dispensing initiative requirements read the Education guide – Continued Dispensing Initiative – PBS requirements.
Information for pharmacists about electronic claiming of PBS or Repatriation Pharmaceutical Benefits Scheme (RPBS) medicines with Medicare.
Our PBS Services status tool provides health professionals with real time information on the operational status of PBS Services and systems, including phone lines.
View the PBS Services status tool.
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:
- 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, and
- for owing prescriptions, the date 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
- you check that both the approval number and claim period number are valid
- you ensure the certification of supply statement is completed by an authorised person, and
- you use the 'Close a Claim' transaction to send the claim to the department for processing
Your declaration should include information about the nature of the loss, such as natural disaster, emergency or misplaced prescriptions. The pharmacy will need to retain this for a period of two years for audit and verification purposes.
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:
Department of Human Services
GPO Box 9826 in your state
Improved Monitoring of Entitlements (IME) is a measure to ensure pharmaceutical benefits are provided only to those people eligible to receive them.
You are unable to charge the patient at the PBS concessional rate.
This is because:
- Medicare's PBS online claiming system, which accesses data directly from Centrelink, indicates the concessional entitlement is not current, and/or
- the patient’s entitlement card has expired
You cannot charge the lower PBS concessional rate if the patient does not have a valid concessional entitlement.
Before pharmacies can provide PBS or RPBS medicine at a subsidised rate, they are required by law to check the patient’s entitlement status to ensure it is valid. This is an Australian Government requirement that ensures only eligible people receive subsidised PBS or RPBS medicine, helping to ensure that the PBS remains sustainable for all Australians.
There could be several reasons why a patient’s card is invalid, including:
- their card has expired
- they have recently changed their name
- their Centrelink payments have stopped
- they have returned from overseas and have not informed Centrelink
- there have been changes in the caring arrangements of their children
- there have been changes in their income
- there have been changes in the living arrangements of either the patient or their partner
If the patient is unsure as to why they are not entitled and you would like to query this matter, you should contact the government agency that issued the card.
|Government agency||Type of Card||Contact us|
|Department of Veterans' Affairs (DVA)||
Repatriation Health Cards:
The customer service officer will be able to provide you with further information.
If the patient pays a higher price for their prescription and it is found that they were actually entitled to the concession rate when they were supplied the medicine, they will be able to claim a refund through Medicare or the Department of Veterans' Affairs (DVA), once they have shown:
- the receipt for the medicine
- their 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 the patient pays – in some cases hundreds of dollars more – but our taxes provide eligible people a subsidy so they pay less. It is therefore important that pharmacies check entitlement cards.
Pharmacists who wish to temporarily 'deactivate' an approval to supply pharmaceutical benefits.
Pharmaceutical Benefits Scheme (PBS) processing reason codes for online claiming by PBS pharmacies.
The National Health Act 1953 requires approved suppliers to supply prescription data for items 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, and
- monitoring the quality use of medicines in the community
Under co-payment prescription data is collected through the online claiming for 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.
Detailed information on how prescription medicines are priced under the PBS and RPBS.
This initiative was introduced to minimise waste and reduce PBS expenditure on chemotherapy medicines used in the treatment of cancer and administered through intravenous infusion or injection.
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 one or more of the following:
- distribution fee
- diluent fee
- preparation fee, or
- dispensing fee
All medicine that meets the criteria for inclusion in the measure, including trastuzumab (Herceptin®), is subject to the new prescribing, dispensing and claiming arrangements.
The table below lists the average 10 g/mL rates payable for extemporaneous items supplied during July 2016 in all states and territories.
The National Residential Medication Chart (NRMC) is designed to improve medication safety for your patients. It also reduces administrative work for prescribers, aged care staff and pharmacists when ordering, administering and supplying medicines.
The NRMC has been tested and evaluated in over 20 residential aged care services by the Australian Commission on Safety and Quality in Health Care. Claims from approved pharmacists can be made using the NRMC and other charts if compliant with state and Commonwealth legislation.
Read more about the NRMC on the Australian Commission on Safety and Quality in Health Care website.
Prescribe and supply medicines from the NRMC
You can prescribe and supply most medicines directly from the NRMC without the need for a separate written prescription. This includes PBS and RPBS claiming by pharmacists where applicable.
Certain medicines still require a written prescription. They also require an order on the NRMC. These medicines include:
- all PBS authority required items that need prior approval by online, telephone or in writing, including PBS or RPBS items with increased quantities
- PBS items only available under section 100, such as some highly specialised drugs. Read more about section 100 items on the PBS website
- controlled drugs, such as Schedule 8 medicines. Contact your state or territory health department for more information on Schedule 8 medicines
- extemporaneously compounded medicines
- medicines that are subject to state or territory restrictions
Authority required (STREAMLINED) items are eligible for supply and PBS claiming using the NRMC. These items are eligible when the prescriber includes the PBS streamlined authority code in the appropriate area of the NRMC for each relevant medicine.