Prescribing medicines Information for PBS Prescribers

2. Prescribing Medicines — Information for PBS Prescribers

PBS prescribers

Pharmaceutical benefits can only be prescribed by registered doctors, and by dentists and optometrists who are approved to prescribe within the PBS.

PBS Prescription forms

Standard PBS prescription forms are available from Medicare Australia for prescribing pharmaceutical benefits.

For doctors:

• Personalised forms – are printed with the doctor's name, qualifications, practice address/es, telephone number and prescriber number (which relates to pharmaceutical benefits). They are only provided to doctors who have a Medicare provider number.
• Non-personalised (blank) forms – are distributed as an emergency supply (usually when a doctor has temporarily run out of personalised forms).
• Locum forms – have the doctor's name, prescriber number and telephone number (if available) and a space to record the practice where the doctor is working.
• PBS/RPBS Authority Prescription Forms – can be in personalised, non-personalised or locum format.
• Computer PBS prescription forms – are either continuous or single sheet. On the reverse side they list the name, address and telephone number of the practice, and in the case of a sole doctor practice, the doctor's name.

For dentists:

• Personalised forms – have the dentist's name, qualifications, practice address/es, telephone number and prescriber number.
• Non-personalised (blank) forms – are distributed for emergency supply only.

For optometrists:

• Personalised forms – have the optometrist’s name, qualifications, practice address/es, telephone number and prescriber number. These forms can be also be used to prescribe authority-required PBS/RPBS items.

PBS prescription forms for PBS prescribers are supplied free of charge.

The inclusion of the prescriber number on a PBS prescription enables the pharmacist to be sure the prescription is from a legitimate prescriber and satisfies State/Territory legislation.  A PBS prescription written by a dentist or optometrist must include the person’s approval number as a PBS prescriber.

PBS prescriptions should be provided to the patient in duplicate, as both parts make up a valid PBS prescription. The patient should be reminded to present both the original and the duplicate copy to the pharmacist.

There are separate arrangements for PBS prescriptions in certain public hospitals. To gain access to pharmaceutical benefits under this arrangement a patient must attend a participating public hospital and be a discharge patient or non-admitted patient. Only a medical practitioner providing medical services within a participating public hospital may prescribe the subsidised medication. The States of Victoria, Queensland, South Australia and Western Australia, and the Northern Territory have agreed to implement these arrangements.

Ordering forms

Prescribers are asked not to over order. Getting the right amount of forms helps to reduce the cost to taxpayers and helps to reduce paper wastage. Also, the pads may deteriorate if stored over time.

Order forms for standard and authority PBS prescription forms are available from Medicare Australia stationery officers.  Order forms for computer PBS prescription form stationery are obtained from Medicare Australia (at the address below). Orders should be sent to:

• Prescription Pad Order Clerk
• Pharmaceutical Branch
• Medicare Australia
• GPO Box 9826
• Sydney NSW 2001
• Telephone (02) 9895 3295

Orders for PBS prescription stationery will only be accepted by application in writing and through the channels mentioned above.

Preparing general PBS prescriptions

Do's and Don't's

A PBS prescription is only valid when it is written by a doctor, dentist or optometrist.

The PBS prescription must be for the treatment of the person named on the PBS prescription. A PBS prescription may only be written for the treatment of one person.

A prescriber cannot write more than one PBS prescription for the same pharmaceutical benefit for the same person on the same day.

Up to three pharmaceutical benefit items may be included on a single PBS prescription form except for Authority required, Authority required (STREAMLINED) items and optometrist items. These items must be written on individual forms. Pharmaceutical benefits and non-pharmaceutical benefits should not be listed together on the one PBS prescription form.

There are separate arrangements for PBS prescriptions in certain public hospitals. To gain access to pharmaceutical benefits under this arrangement a patient must attend a participating public hospital and be a discharge patient or non-admitted patient. Only a medical practitioner providing medical services within a participating public hospital may prescribe the subsidised medication. The States of Victoria, Queensland, South Australia and Western Australia, and the Northern Territory have agreed to implement these arrangements.

If an item has a particular manner of administration it may not, as a pharmaceutical benefit, be administered in any other way, e.g., an ophthalmic preparation may not be prescribed for topical use.

If an item is restricted, but the patient is not suffering from one of the specified conditions, it cannot be prescribed as a pharmaceutical benefit. The prescriber should write the prescription either on a private prescription or on a standard prescription with 'PBS/RPBS' clearly struck out. It should also be endorsed 'non-PBS'.

Prescribers must heed State/Territory laws when prescribing drugs listed as narcotic, specified or restricted in the poisons legislation of the particular State or Territory. Legislative requirements in some States/Territories are such that prescribers may be required to prescribe a drug of addiction on a separate PBS prescription. Optometrists must ensure that prescriptions written under the PBS fall within the limits of the prescribing approval granted to the person under State or Territory requirements. It is the optometrist’s responsibility to ensure that PBS prescriptions comply with all aspects of his/her prescribing approval. Inclusion of a PBS medicine in the optometrist listings does NOT confer approval for an optometrist to prescribe that medicine if not authorised to do so in the particular State or Territory.

A prescriber cannot prescribe a narcotic drug for him/herself.

Prescribers are issued with individual PBS prescription pads by Medicare Australia for their own use – these pads should not be used by other prescribers, as this can cause confusion through incorrect pharmacy records.

Doctors should, and dentists and optometrists are required to, include their prescriber numbers on non-personalised PBS prescriptions.

The following admixtures are not pharmaceutical benefits:

• the admixture of two or more ready-prepared items listed in the Schedule; or
• the admixture of a ready-prepared item and one or more extemporaneous drugs listed in Section 4 of the Schedule; or
• the admixture of a non-pharmaceutical benefit item with a pharmaceutical benefit item.

Writing the PBS prescription

The following rules apply for writing PBS prescriptions:

• they must be written in indelible form (i.e., ink or ball-point pen) in the prescriber's own handwriting (exceptions must be approved by Medicare Australia's Chief Executive Officer) either on the standard PBS prescription, or on paper approximately 18 cm x 12 cm, or they can be generated by computer on a form approved by Medicare Australia. For patient safety reasons, both the original and the duplicate must be legible;
• they must record the prescriber's name and address (and, in the case of dentists and optometrists, the prescriber number), the patient's name, address and entitlement status, and whether the prescription is under the PBS or RPBS;
• they should completely identify the pharmaceutical benefit by detailing the item, dose, form, strength, quantity and instructions for use;
• they should indicate where brand substitution is not permitted. PBS prescriptions must not be prepared using a computer prescribing program that contains a default which would result in all prescriptions being indicated as Brand Substitution Not Permitted;
• where 'solvent required' is included after the form, the volume and number of ampoules must be specified; and
• they must be signed by the prescriber and dated. Forward or back dating is not permitted.

There are separate arrangements for PBS prescriptions in certain public hospitals. To gain access to pharmaceutical benefits under this arrangement a patient must attend a participating public hospital and be a discharge patient or non-admitted patient. Only a medical practitioner providing medical services within a participating public hospital may prescribe the subsidised medication. The States of Victoria, Queensland, South Australia and Western Australia, and the Northern Territory have agreed to implement these arrangements.

Restrictions

Pharmaceutical benefits listed in the Schedule fall into three broad categories:

Unrestricted benefits –have no restrictions on their therapeutic uses;

Restricted benefits –can only be prescribed for specific therapeutic uses (noted as Restricted benefit); and

Authority required benefits –Authority required benefits fall into two categories:

• Authority required benefits are restricted benefits that require prior approval from Medicare Australia or the DVA (noted as Authority required)
• Authority required (STREAMLINED) benefits are restricted benefits that do not require prior approval from Medicare Australia or the DVA but require the recording of a streamlined authority code (noted as Authority required (STREAMLINED)).

Authority PBS prescriptions

Authority required benefits fall into two categories – Authority required and Authority required (STREAMLINED).

Only doctors and optometrists (not dentists) can write authority PBS prescriptions.

Authority PBS prescriptions cannot have retrospective approval.

Authority required PBS Prescriptions

Approval of authority PBS prescriptions by Medicare Australia may be sought by: 

• posting an Authority Prescription Form to Medicare Australia - after approval, Medicare Australia will forward both copies of the prescription to the patient or the prescriber (if it is to be sent direct to the patient, the prescriber should mark the box next to the patient's details);
• calling Medicare Australia Authority Freecall service (1800 888 333); or
• using Medicare Australia PBS authorities website at www.medicareaustralia.gov.au/providers.

Approval of authority prescriptions by the DVA may be obtained either by posting an Authority Prescription Form to the DVA, or by using the DVA Authority Freecall service (1800 552 580).

An authority PBS/RPBS prescription is not valid until it has been approved by Medicare Australia or the DVA. Without this approval, a pharmacist must not supply the item as a PBS/RPBS benefit.

Each Authority required PBS/RPBS item must be written on an Authority PBS/RPBS prescription form, one item per form.  Authority PBS prescription forms provide for the following:

• the patient/pharmacist copy, which records prescriber, patient, and pharmaceutical benefit item details. Where required a repeat authorisation, which is used for repeat supply, is attached to the pharmacist/patient copy until the last supply is made. The patient/pharmacist copy is then retained by the pharmacist;
• the Medicare Australia/DVA copy which records prescriber, patient, and pharmaceutical benefit item details. After the first dispensing, the Medicare Australia/DVA copy is forwarded to Medicare Australia for processing and payment;
• the prescriber's copy (for computer generated scripts, this is the tear off portion at the base of the script) or Prescriber/Medicare Australia/DVA copy (for handwritten scripts this is the long white copy), is kept by Medicare Australia or the DVA for record purposes when approval is sought in writing. When approval is by telephone or by the authorities website, the prescriber must keep this copy for 12 months. This copy must record the daily dose, details of the disease, clinical justification for using the item, the patient's age (if the patient is a child) and whether the patient has previously received an authority for this pharmaceutical benefit.

There are separate arrangements for PBS prescriptions in certain public hospitals. To gain access to pharmaceutical benefits under this arrangement a patient must attend a participating public hospital and be a discharge patient or non-admitted patient. Only a medical practitioner providing medical services within a participating public hospital may prescribe the subsidised medication. The States of Victoria, Queensland, South Australia and Western Australia, and the Northern Territory have agreed to implement these arrangements.

Authority required (STREAMLINED) PBS Prescriptions

Prior approval is not required from Medicare Australia or DVA to prescribe an Authority required (STREAMLINED) item (except where increased quantities and/or repeats are required). Instead the authority prescription form must include a four digit streamlined authority code.

This code is listed with the corresponding restriction for each Authority required (STREAMLINED) item and the prescriber must write the code on the authority PBS/RPBS prescription form. An authority prescription for an Authority required (STREAMLINED) item is not valid unless the code is included on the prescription form. Without the streamlined authority code, a pharmacist must not supply the item as a PBS benefit.

There are no Authority Required (STREAMLINED) items in the Repatriation Schedule of Pharmaceutical Benefits.

Authority required (STREAMLINED) PBS prescriptions must be written on an Authority PBS/RPBS Prescription Form, this includes:

• the pharmacist/patient copy, which records prescriber, patient, and pharmaceutical benefit item details. The prescription is given directly to the patient to be dispensed at their pharmacy;
• the Medicare Australia/DVA copy which records prescriber, patient, and pharmaceutical benefit item details. After the first dispensing, the Medicare Australia/DVA copy is forwarded to Medicare Australia for processing and payment;
• the prescriber's copy is kept by the prescriber for 12 months. This copy must record the daily dose, details of the disease, clinical justification for using the item, the patient's age (if the patient is a child) and whether the patient has previously received an authority for this pharmaceutical benefit.

There are separate arrangements for PBS prescriptions in certain public hospitals. To gain access to pharmaceutical benefits under this arrangement a patient must attend a participating public hospital and be a discharge patient or non-admitted patient. Only a medical practitioner providing medical services within a participating public hospital may prescribe the subsidised medication. The States of Victoria, Queensland, South Australia and Western Australia, and the Northern Territory have agreed to implement these arrangements.

Writing authority PBS prescriptions

The following rules apply:

• only one item may be prescribed per PBS prescription;
• PBS prescriptions must be completed by prescribers in writing, unless otherwise approved by Medicare Australia;
• prescribers should include their name, address, telephone number and prescriber number (not provider number);
• prescribers must include the patient's name, address and entitlement status (i.e. whether they are a 'concessional' or 'general patient';
• prescribers must indicate when brand substitution is not permitted. PBS prescriptions must not be prepared using a computer prescribing program that contains a default which would result in all PBS prescriptions being indicated as Brand Substitution Not Permitted;
• in certain circumstances, the prescriber must provide additional information to Medicare Australia with the authority application; and
• the PBS prescription must be signed by the prescriber and dated.

Posted applications which lack necessary information, and therefore cannot be approved, will be returned for correction. If the matter can be clarified via telephone, an Authority to Prescribe Form may be prepared by Medicare Australia or the DVA and sent to the prescriber.

In the case of authority PBS prescriptions approved by telephone, the approval number must be included on the PBS prescription to enable the pharmacist to supply the medication. A prescriber who is granted approval but decides not to continue with the therapy should advise Medicare Australia.

In the case of Authority required (STREAMLINED) prescriptions, the streamlined authority code must be written on the PBS/RPBS prescription form. This enables the pharmacist to supply the medication as a PBS benefit.

There are separate arrangements for PBS prescriptions in certain public hospitals. To gain access to pharmaceutical benefits under this arrangement a patient must attend a participating public hospital and be a discharge patient or non-admitted patient. Only a medical practitioner providing medical services within a participating public hospital may prescribe the subsidised medication. The States of Victoria, Queensland, South Australia and Western Australia, and the Northern Territory have agreed to implement these arrangements.

Maximum quantities and repeats

The maximum quantity and number of repeats allowed for PBS items are recommended by the Pharmaceutical Benefits Advisory Committee (PBAC).  In the case of RPBS items, the recommendations are made by the Repatriation Pharmaceutical Reference Committee (RPRC).

Only doctors and optometrists (not dentists) can prescribe repeats.

PBS prescriptions and repeats can be for any quantity up to the maximum. It is not necessary to prescribe the maximum quantity if a lesser quantity is sufficient for the patient's needs. Please clearly indicate the number of tablets, capsules, etc. required and the number of repeats needed, and do not use abbreviations such as 'Max. Qty', 'M.Q.', or 'M.R.'.

If a prescriber feels the maximum quantity or number of repeats should be increased for a particular patient, he or she must complete an Authority PBS Prescription Form (see procedures above under 'Authority PBS Prescriptions'). The provision of increased quantities and repeats on authority PBS prescriptions is intended to provide approximately one month's therapy which may be repeated (if clinically appropriate) to provide 6 months' therapy in total. This situation usually arises where higher than normal dosages are required.

Approval for increased quantities and repeats of Authority required, Authority required (STREAMLINED) and Restricted benefit PBS items will be granted only where the reason for the PBS prescription is consistent with the indications published in the Schedule.

Approval for increased quantities and repeats extends only to the provision of a pharmaceutical benefit for the patient and does not imply approval of any aspects of the patient's care, which are the responsibility of the treating prescriber.

Regulation 24

Under this regulation, original and repeat supplies of pharmaceutical benefits can be supplied at the one time if a doctor is first satisfied that certain conditions apply, then endorses the PBS prescription `Regulation 24'. RPBS prescriptions may be endorsed 'hardship conditions apply'.

The doctor must first be satisfied all the following conditions apply:

• the maximum PBS quantity is insufficient for the patient's treatment; AND
• the patient has a chronic illness or lives in a remote area where access to PBS supplies is limited; AND
• the patient would suffer great hardship trying to get the pharmaceutical benefit on separate occasions.

Regulation 24 does not apply for supply of pharmaceutical benefits on optometrist prescriptions.

Urgent cases

In urgent cases and where State/Territory law allows, a prescriber may telephone a pharmacist and ask that a PBS prescription be supplied. He/she must then forward the written PBS prescription and duplicate to the pharmacist within seven days of the date of supply.

This also applies to 'Authority required' authority PBS prescriptions provided prior approval has been given by Medicare Australia or DVA. The follow-up written PBS prescription must include the approval number provided over the phone by Medicare Australia or DVA.

Drugs of addiction

Prescribers must heed State/Territory laws when prescribing drugs listed as narcotic, specified or restricted and must notify, or receive approval from, the appropriate health authority.

When a PBS/RPBS authority application is for a drug of addiction (other than dexamphetamine sulfate), the following guidelines apply:

• the maximum quantity authorised is generally for one month's therapy (e.g., one week's therapy with three repeats);
• where supply for a longer period is warranted, quantities are usually for up to three months' therapy;
• telephone approvals are limited to one month's therapy.

Doctors should also state the interval of repeat where repeats are called for, and ensure State/Territory health authorities are notified about ongoing treatment.

Emergency drug (doctor's bag) supplies

Certain pharmaceutical benefits are provided without charge to prescribers who in turn can supply them free to patients for emergency use.

The Emergency Drug (Doctor's Bag) Order Form must be completed in triplicate, signed, and the original and duplicate given to a pharmacist. Each form is valid for the month indicated on the form.

Prescribers may order the maximum quantity of an item provided they do not already have the maximum quantity on hand. The items can only be obtained once a month. Prescribers may also ask for a particular brand of a pharmaceutical benefit. If it is unavailable, they must specify another listed brand, and initial the alteration.

A receipt must be signed by the prescriber, or by an authorised representative, when supplies are received.

Availability of Methoxyflurane for emergency treatment only

A new Emergency Treatment Program (ETP) has been established to provide for medicines such as Methoxyflurane to be supplied as doctor’s bag items for emergency treatment, other than hospital treatment. Unlike other emergency drug supplies, Methoxyflurane, liquid for inhalation 999.9 mg per g, 3 mL (with inhaler) (Penthrox^® ) is not available for prescribing as a general pharmaceutical benefit.

Methoxyflurane is therefore PBS-listed as a ‘special pharmaceutical product’ under section 100AA, only for emergency treatment, other than hospital treatment. As such, the availability of this drug is provided for under special arrangements under section 100 (1) of the National Health Act 1953. The legislative instrument can be viewed on the Federal Register of Legislative instruments at www.frli.gov.au.

For the purposes of administration, Methoxyflurane will be listed with other emergency treatment drugs in the Doctor’s Bag list, as outlined above, and managed by Medicare Australia in the same manner as other doctor’s bag items with the same supply and claiming procedures.

Improving the capacity of the PBS to meet particular Aboriginal and Torres Strait Islander health needs

The PBS includes listings to support the treatment of conditions common in Aboriginal and Torres Strait Islander health settings. These listings are specifically for your patients who identify as Aboriginal and/or Torres Strait Islander persons. Some listings will be medicines recently added to the PBS; others may contain specific restrictions for existing PBS items.  Details of these listings can be found in the fact sheet, Listings on the PBS for Aboriginal and Torres Strait Islander people.

A significant proportion of the higher levels of illness experienced by Aboriginal and Torres Strait Islanders may be addressed through better access to appropriate medicines. The PBS aims to provide greater choice in therapeutic options and to address:

• the greater burden of disease experienced by Aboriginal and Torres Strait Islander peoples; and 
• morbidity almost exclusively seen in this population.

How to prescribe these items?

These items are available as "Authority PBS prescriptions". You should obtain approval from Medicare Australia before prescribing these items for patients who identify as Aboriginal and/or Torres Strait Islander persons through the Authority Freecall service [1800 888 333], on line or by mail.

Only doctors (not dentists) can write Authority PBS prescriptions and your patients will be required to pay their normal PBS co-payment.

Special arrangements apply in remote area Aboriginal Health Services for supplying these PBS items.

Aboriginal and Torres Strait Islander identification

Establishing a client’s background may have clinical significance and should be part of routine medical history taking. In the case of Aboriginal and Torres Strait Islander people, this is also relevant to establish eligibility for services such as health checks, specific immunisation programs, and the some PBS items.

Improving the level of identification of Aboriginal and Torres Strait Islander people will also assist in developing initiatives to meet particular needs.

For the purposes of these PBS items a person is Aboriginal and/or Torres Strait Islander if the person identifies himself or herself as being an Aboriginal and/or Torres Strait Islander. Clients should be asked to self-identify either verbally or by completing a form.

• Some people may give this information without being asked. 
• It is important not to assume that a person is or is not Aboriginal or Torres Strait Islander.

Asking about Aboriginal and/or Torres Strait Islander identification

 Practitioners should ensure that each person attending their practice has the opportunity to identify if they are Aboriginal or Torres Strait Islander. An environment which maintains confidentiality and provides an explanation for this question if requested will assist this process.

• The inquiry may be made verbally and recorded by the general practitioner as part of routine medical history taking at first consultation, or by a receptionist or other staff member. An appropriate question to ask is:
  "Are you (is this child) of Aboriginal or Torres Strait Islander origin?"
• Alternatively, the question may be included on a client self-history or practice record form, using a standard question such as:
  "Are you (is this child) of Aboriginal or Torres Strait Islander origin?"
  • Yes - Aboriginal
  • Yes - Torres Strait Islander
  • Yes - Aboriginal and Torres Strait Islander
  • No
    

Aboriginal and Torres Strait Islander health

Major causes of excess mortality in Aboriginal and Torres Strait Islander peoples are:

• circulatory conditions (including ischaemic heart disease, hypertension, cerebrovascular disease and rheumatic heart disease);
• external causes (including accident and injury);
• endocrine causes (mainly type two diabetes and its complications); and
• respiratory conditions.

Causes of morbidity vary but include the risk factors and precursors of all of these. They also include infections of the respiratory system, the ears (in particular, chronic suppurative otitis media), the eyes (trachoma in some settings), the skin and the gastrointestinal system. End-stage renal disease is a major cause of hospitalisations, and much early renal disease remains undetected. In some settings, sexually transmissible infections are common.

Living environments affect health and may be compromised by overcrowding, limited access to clean water and sanitation, and poverty. Social and family life may be negatively influenced by an excessive burden of care for family members, by substance use and sometimes by family violence.

Communication and cultural issues

 Aboriginal cultures are numerous and diverse in language, customs, non-verbal and verbal communication, geographical locations and experiences. Torres Strait Islanders are a separate people with a distinctly different culture and identity. Aboriginal and Torres Strait Islander people often perceive health differently from other Australians.

For Aboriginal and Torres Strait Islander peoples health does not just entail the freedom of the individual from sickness but requires support for healthy and interdependent relationships between families, communities, land, sea and spirit. The focus must be on spiritual, cultural, emotional and social well-being as well as physical health

Source: National Aboriginal and Torres Strait Islander Health Council. National Strategic Framework for Aboriginal and Torres Strait Islander Health 2003-2013, Context. Canberra: Commonwealth of Australia; 2004.

To provide effective primary health care to Aboriginal and Torres Strait Islander clients, you need to be aware of the issues surrounding this diversity, and which may have an impact on the delivery of services.

• Aboriginal and Torres Strait Islander people may be reluctant to use mainstream medical services. This may be because of a lack of understanding of the mainstream health system and previous negative experiences within the mainstream health care system.
• Access to adequate health care may be hindered by family obligations (often extended family), lack of transport or money, or geographical isolation.
• English may be the person’s second, third or even fourth language. Therefore it may be appropriate to consider the use of an interpreter.
• Aboriginal and Torres Strait Islander people may be reluctant to consult a health care provider of the opposite sex, particularly with regard to women’s and men’s health issues.

The differences between the cultural and language backgrounds of health service providers and patients, whether urban, rural or remote, may range from minor to extreme.

You should:

• Make efforts to ensure waiting rooms are welcoming to Aboriginal and Torres Strait Islander people, including displaying relevant posters and pamphlets;
• Provide a relaxed setting for the consultation (e.g. sit next to your patient rather than across a desk);
• Allow time at the first consultation to build rapport and trust;
• Ensure the person understands clearly what the service entails and the details of any procedures involved, and possible follow-up or referral requirements;
• Obtain health promotion information appropriate for Aboriginal and Torres Strait Islander patients;
• Allow the patient to have family members present if desired. When inviting family or community members to accompany a patient, ensure the patient fully consents to their attendance and that the community/family members are fully aware of the need for confidentiality;
• Provide gender appropriate staff where possible, for both male and female patients, especially in regard to pap smears, mammograms, sexual health checks, pregnancy checks, antenatal care and postnatal care;
• Encourage all staff in the practice to attend Aboriginal and Torres Strait Islander Cultural Awareness programs, which are widely available;
• Ensure practice staff have awareness of appropriate referral and/or support organisations for Aboriginal and Torres Strait Islander patients; and
• Develop partnerships with local Aboriginal and Torres Strait Islander community organisations.

For more information, pbs-indigenous@health.gov.au