Patient eligibility

Patient eligibility for highly specialised drugs.

Eligibility

An eligible patient:

  • is, or is to be treated as, an eligible person within the meaning of the Health Insurance Act 1973 (the Act), and
  • receiving appropriate specialist medical treatment by an approved prescriber, or from a hospital as:
    • a non-admitted patient
    • a day admitted patient, or
    • a patient on discharge

An eligible person is defined by the Act as one of the following:

  • an Australian resident
  • a person covered by a Reciprocal Health Care Agreement (RHCA), or
  • an eligible overseas representative

An Australian resident is a person who resides permanently in Australia and is one of the following:

  • an Australian citizen
  • a person who holds a permanent visa
  • a New Zealand citizen, or
  • an applicant for permanent residence in certain circumstances - not a parent applicant who has a valid visa with permission to work or has a parent, spouse or child who is an Australian citizen or holds permanent resident status with an interim Medicare card

Eligible overseas representative means:

  • the head of a diplomatic mission or consular post, established in Australia, of those countries with which Australia has an Reciprocal Health Care Agreement except for New Zealand and Norway
  • staff of those diplomatic missions or consular posts, or
  • family members of heads or staff of those diplomatic missions or consular posts

Eligible overseas persons will have a Medicare card.

An eligible person who has enrolled in Medicare and has not yet received their card can use their Medicare card receipt with their Medicare number printed on it as evidence of eligibility.

Reciprocal Health Care Agreement

If a patient is entitled to be treated as an eligible person as a visitor from a country with which Australia has entered into a Reciprocal Health Care Agreement, the supply will be limited to the original prescription only. Repeat prescriptions for these patients are not permitted.

Read more about Reciprocal Health Care Agreements.

Patient contribution

All eligible patients need to pay a contribution fee for each supply of PBS or Repatriation Pharmaceutical Benefits Scheme (RPBS) HSDs. The fee may be general, concessional or an entitlement.

Page last updated: 22 February 2019