Improved Monitoring of Entitlements to pharmaceutical benefits

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

Background

Improved Monitoring of Entitlements (IME) is a measure to ensure we only provide pharmaceutical benefits to eligible people.

The IME is supported by the National Health Amendment (Improved Monitoring of Entitlement of Pharmaceutical Benefits) Act 2000.

For pharmacists to receive payments for dispensing prescriptions:

  • they need to provide the patient's Medicare card number or Veterans' Affairs file number with their claim
  • the patient’s concession card number has to match the one we have recorded.

This is so that when pharmacists make a PBS claim, we can identify the customer and check their eligibility.

Benefits

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

The IME doesn’t change patient entitlements for medications listed on the PBS.

Proof of eligibility

Most people only need to provide their Medicare card number when they get prescriptions filled for PBS subsidies medicines.

To receive an additional subsidy, concession card holders also have to provide their concession card number.

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

White card holders have 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 receive PBS subsidised medication.

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

Sometimes people who are entitled to receive pharmaceutical benefits may not be able to provide a Medicare card number. Customers who don’t know their Medicare number can either:

If an eligible customer doesn’t know their number, they can pay the full price for the medication and get a refund later. They can get a refund from a Medicare office or DVA state office. They’ll need a PBS patient refund receipt from the pharmacy.

Pharmacists can contact us on the PBS general enquiries line to get a customer’s:

  • Medicare or Veteran's card number
  • expiry date to use in PBS claims.

The pharmacist will need the patient’s consent.

We can release a maximum of 5 numbers and expiry dates per call.

Medicare special numbers

In some circumstances, people who are entitled to receive pharmaceutical benefits may not be able to provide a Medicare number. We established special Medicare numbers to cover situations where consumers are eligible but can’t produce their number. This could be, for example, in an emergency or if the patient is an eligible overseas visitor.

The National Health (Entitlement to Pharmaceutical Benefits - Special Evidentiary Categories) Determination 2001 supports the use of Medicare special numbers.

Pharmacists can use one of the special numbers if the circumstances fit. There are 6 Medicare special numbers available for pharmacists to use in these circumstances. These are shown in the table below.

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

Compliance

We encourage people to voluntarily comply with the programs we administer.

We monitor the use of Medicare special numbers and we’ll conduct audits to check pharmacists are using them appropriately. It’s the pharmacist’s responsibility to make sure they use Medicare special numbers appropriately.

Page last updated: 25 October 2018