4. Patient Charges

Page last updated: 11 March 2016

Type of patient

There are two types of PBS beneficiaries, general patients, who hold a Medicare card, and concessional patients, who hold a Medicare card and one of the following:

  • Pensioner Concession Card
  • Commonwealth Seniors Health Card
  • Health Care Card
  • Repatriation Health Card for All Conditions (gold) — concessional patients under RPBS
  • Repatriation Health Card for Specific Conditions (white) — only regarded as concessional patients for RPBS prescriptions unless they hold a separate entitlement from Centrelink, otherwise they are general patients
  • Repatriation Pharmaceutical Benefits Card (orange) — concessional patients under RPBS
  • Safety Net Concession Card or Safety Net Entitlement Card — issued by the Department of Human Services.

Concessional patients are recognised by public hospitals in all States and Territories apart from South Australia (where DVA beneficiaries are treated as general patients) and New South Wales (where holders of a white DVA card are treated as general patients).

Under the Reciprocal Health Care Agreements, visitors from participating countries (see the introduction of this section for the list of countries) are treated as general patients and do not have concessional entitlements. To receive pharmaceutical benefits these visitors may need to present a temporary Medicare card or their passport. Pharmacists should contact the Department of Human Services if they have enquiries about these arrangements.

Establishing entitlement

PBS prescription forms supplied by the Department of Human Services have spaces provided for details of a patient's entitlement status. Anyone can enter this information, which must include:

  • a cross (x) in the appropriate box to indicate the level of patient contribution;
  • the complete Medicare number (including individual reference number) or complete Veteran file number on the card; and
  • if applicable, the complete concession number on the card.

The person who signs the receipt for pharmaceutical benefits also accepts responsibility for the validity of the entitlement information on the PBS prescription.

All PBS prescriptions must have a Medicare or Veteran file number. All concessional PBS prescriptions must have a concession number. However, it is not necessary for the Medicare or Veteran file number, or the concession number to be endorsed on the PBS prescription if it is included in the electronic prescription details supplied by a pharmacist who is using the Claims Transmission System.

What to charge

Patient contribution

Under the PBS, the maximum cost for a pharmaceutical benefit item at a pharmacy is $38.30 for general patients and $6.20 for concessional patients, plus any applicable special patient contribution, brand premium or therapeutic group premium. General patients who have reached the Safety Net threshold (see details under '5. The Safety Net Scheme') may receive pharmaceutical benefits at the concessional rate, plus any applicable special patient contribution, brand premium or therapeutic group premium. From 1 January 2016, pharmacists have the option to discount the PBS patient co-payment by up to $1.00 (unless the prescription is an early supply of a specified medicine, in which case, the full co-payment applies).

Patients who have a Safety Net Entitlement Card (see details under '5. The Safety Net Scheme') may receive PBS items free of charge, except for any applicable special patient contribution, brand premium or therapeutic group premium.

The contribution rate for general patients as outpatients at public hospitals in most of Australia is $30.60. The exceptions are in hospitals participating in the pharmaceutical reforms where they pay the Safety Net value of an item listed in the Schedule (see details under '5. The Safety Net Scheme'), or up to the general co-payment amount for items not listed in the Schedule. The public hospital pharmaceutical reforms enable participating public hospitals to prescribe and supply pharmaceutical medication from the PBS to outpatients and patients upon discharge. A range of chemotherapy drugs is also available for day-admitted and non-admitted chemotherapy patients.

The contribution rate for concessional patients in all public hospitals is equal to the concessional co-payment amount.

The supply of a pharmaceutical benefit or a Repatriation pharmaceutical benefit to a patient is GST-free. Goods and services tax must not be included in the price charged to a patient for the supply of a PBS or RPBS script.

It is the patient's responsibility to pay any charge lawfully imposed by an approved pharmacist or supply may be refused.

The patient contribution rates are adjusted on 1 January each year in line with inflation.

Patient contributions for early supply of some PBS medicines

Prescriptions for some PBS and RPBS pharmaceutical benefits are not eligible for Safety Net benefits if re-supplied within a specified period following a previous supply of the same or an equivalent pharmaceutical benefit for the same person. Early supply arrangements were introduced in 2006 as the ‘Safety Net 20 day rule’. From 1 January 2016, expanded PBS early supply provisions replace the Safety Net 20 day rule and extend early supply rules to more medicines.

Where a prescription is subject to the Safety Net early supply rules:

  • the patient contribution does not count towards the Safety Net;
  • after the Safety Net threshold is reached, the usual patient co-payment amount for the person's entitlement level (not the Safety Net amount) applies; and
  • discounting of the patient co-payment is not permitted.

The option for pharmacists to discount PBS co payments by up to $1.00 does not apply for early supply prescriptions.

For example: The payment for an early supply prescription for a patient with a Safety Net Entitlement Card would be the full concessional co-payment amount — not free. For a general patient with a Safety Net Concession Card, the full general co-payment amount would apply — not the concessional amount.

The Safety Net early supply rule does not apply to PBS/RPBS prescriptions originating from hospitals.

Special patient contributions, brand premiums and therapeutic group premiums

A special patient contribution is payable for a pharmaceutical benefit when a supplier will not supply it at the benchmark price. Any extra charge for a higher priced benefit is paid by the patient, together with their usual patient contribution. Exemptions on medical grounds are available, but must be granted by the Department of Human Services. For RPBS special patient contribution arrangements see the RPBS Explanatory Notes.

Under the brand premium arrangements, reimbursement to pharmacists is based on the lowest-priced brand. Any extra charge for a higher priced brand is paid by the patient, together with their usual patient contribution.

Under the therapeutic group premium arrangements, reimbursement to pharmacists is based on the lowest priced benefit items within identified therapeutic groups. Any extra charge for a higher priced benefit is paid by the patient, together with their usual patient contribution. Exemptions on medical grounds are available, but must be granted by the Department of Human Services.

Special patient contributions, brand premiums and therapeutic group premiums apply to maximum quantities. When a quantity is less than, or — on an authority or 'Regulation 24' PBS prescription — more than, the maximum, the contributions or premiums will be a factor of the maximum quantity, using standard pricing rules.

There are separate arrangements for PBS prescriptions in certain public hospitals. To obtain pharmaceutical benefits under these arrangements a patient must attend a participating public hospital and be a discharge patient or non-admitted patient. Only a medical practitioner providing medical treatment or a midwife providing midwifery treatment or a nurse practitioner providing nurse practitioner treatment in a participating public hospital may prescribe PBS subsidised medication. Victoria, Queensland, South Australia, Western Australia, Tasmania and the Northern Territory have these arrangements.

Increased quantities

Where a prescriber has written an authority PBS prescription for a quantity greater than the listed maximum quantity, one patient contribution should be charged for each supply of the increased quantity.

Regulation 24

For 'Regulation 24' PBS prescriptions, a pharmacist should charge the usual patient contribution for the original and for each repeat quantity needed to make up the equivalent of the total supply (plus any applicable special patient contribution, brand premium or therapeutic group premium, for the original and each repeat quantity in the total supply).

For early supply purposes, Regulation 24 prescriptions are treated as a single supply.  Usual Safety Net benefits apply for the entire supply if the interval between the Regulation 24 supply and the previous supply is greater than the specified period for the medicine.  If the Regulation 24 supply is an early supply (made within the specified period), Safety Net benefits do not apply for the original or any repeats making up the equivalent of the total supply.

After hours

A pharmacist may charge an extra fee if supplying a PBS item outside normal trading hours. This charge is paid by the patient and does not count towards the Safety Net.

Delivery

A charge can be added for delivering pharmaceutical benefits from the pharmacy. This charge does not count towards the Safety Net. For RPBS delivery arrangements refer to the RPBS Explanatory Notes.