7. How Pharmacists Claim Reimbursement: Information Required
Page last updated: 29 August 2018
The Department of Human Services uses a computerised system for pricing PBS prescriptions, repeat authorisations and prescriber bag supply orders, and for calculating claims.
The payment system is designed to pay pharmacists correctly for the pharmaceutical benefits they supply. It is essential instructions are followed carefully and that each document includes all relevant information. Accurate and complete data ensures claim ayment is not delayed.
PBS Prescription identification
Pharmacists must include certain information on each PBS prescription sent in for claim, as specified below. It is important that this information is entered correctly and in the right place on the PBS prescription. This information will be included in a sticker produced by pharmacy software.
The sticker should be placed on the extreme left front of a PBS prescription, opposite each item being claimed. It must not obscure any details written by the prescriber. Most prescribers use PBS prescriptions, which have space for the sticker. If a sticker is not used, a PBS prescription identification stamp can be used or the information can be written in the same place, and in the same order.
Pharmacists should avoid writing over, or placing the sticker over, the prescriber number pre-printed on PBS/RPBS prescriptions, or the prescriber number box on PBS dental and optometrist, midwife and nurse practitioner prescriptions.
The sticker is not necessary for current repeat authorisation, prescriber bag supplies, or for old style authority PBS prescription and authority to prescribe forms, as they have printed spaces for the necessary details. However, it is required for the new format authority PBS prescription forms.
The following information should be entered next to the appropriate letter on the sticker or stamp:
- 'S' — the serial number for the claim
- 'A' —
- the price claimed for pricing elected PBS prescriptions, exceptional PBS prescriptions and RPBS non-scheduled prescriptions (see under 'Extemporaneously-prepared pharmaceutical benefits not listed in the Standard Formulae List' for explanations of pricing elected PBS prescriptions and exceptional PBS prescriptions); and/or
- confirmation that the PBS prescription is endorsed ‘one supply’ or ‘1 supply’, or the RPBS prescription is endorsed 'hardship conditions apply'; and/or
- a claim for a glass dropper bottle where applicable; and/or
- any clarification of the prescription which will assist the Department of Human Services payment processing.
PBS prescription, repeat authorisation, authority PBS prescription, and prescriber bag order forms submitted in each claim must bear consecutive serial numbers starting with:
- 1 – for prescriber bag supplies;
- 1 – for general benefits;
- C1 – for concessional and Safety Net Concession Card benefits;
- E1 – for Safety Net Entitlement Card benefits; and
- R1 – for RPBS benefits.
Each serial number should also be noted on any document kept by the pharmacist for record purposes.
Each prescriber bag item should be given a serial number, e.g., if there are five items on the first form in the claim, the first item on the second form in the claim will start ith the serial number 6.
For prescriptions subject to the Safety Net 20 day rule, the serial number corresponds to the resulting payment category for the pharmaceutical benefit as supplied, not the patient's entitlement category.
Repeat authorisations for authority PBS prescriptions
When a benefit is supplied on a repeat authorisation which needed an authority PBS prescription, the serial number must be prefixed with the letter 'A' for a general benefit; 'AC' for a concessional benefit or a benefit supplied to a Safety Net Concession Card holder; 'AE' for a Safety Net Entitlement Card holder; or 'AR' for a RPBS benefit.
Repeat authorisations for deferred supply
When a benefit is supplied on a repeat authorisation prepared for deferred supply, the serial number must be prefixed with the letter 'D' for a general benefit; 'DC' for a concessional benefit or a benefit supplied to a Safety Net Concession Card holder; 'DE' for a Safety Net Entitlement Card holder; or 'DR' for a RPBS benefit.
Dispensed prices for extemporaneously-prepared eye drops, ear drops and nasal instillations include the price of a polythene dropper container. However, if a glass dropper container is supplied, payment should be claimed by writing 'glass bottle' in box 'A' of the stamp.
Extemporaneously-prepared pharmaceutical benefits not listed in the Standard Formulae List
When a formula is not listed on the Standard Formulae List, the PBS prescription is paid at an average of 10 g/mL rate for the type of preparation, unless the pharmacist elects otherwise. A pharmacist may price an exceptional PBS prescription, or elect to price all non-pre-priced extemporaneous PBS prescriptions.
PBS prescriptions paid on an average price basis
If the PBS prescription is to be claimed as an exceptional PBS prescription, the pharmacist should write details of the formula supplied on the PBS prescription or repeat authorisation form; price the PBS prescription in accordance with the pricing principles (as detailed in '9. Pricing PBS Prescriptions'); and enter the calculated price on the sticker.
An exceptional PBS prescription is for an extemporaneously-prepared pharmaceutical benefit that is not included in the Standard Formulae List and for which the price of the ingredients (based on basic pricing rules) is twice or more than the recovery price of the ingredients calculated on an average price basis. Further information on pricing PBS prescriptions can be accessed from the book let titled Explanation of Current Pricingon the Department of Human Services' website at www.medicareaustralia.gov.au (PBS publications for Health Care Providers).
Pricing non-pre-priced extemporaneous preparations
Pharmacists should notify the Department of Human Services when they elect to price non-pre-priced extemporaneous preparations. Each PBS prescription should be priced in accordance with the pricing principles and that price entered on the sticker.
RPBS prescriptions for items not included in either the PBS or RPBS Schedule
When a prescription for a RPBS patient is for an item not included in either the PBS or the RPBS Schedule, the price claimed should be entered on the sticker. Full details on pricing and availability of such items under the RPBS are set out in the RPBS Explanatory Notes.
Payment to Pharmacists for Dispensing Premium-free Substitutable Medicines
Premium Free Dispensing Incentive payments will commence for eligible PBS listed products dispensed from 1 August 2008. Premium Free Dispensing Incentive payments will be available to approved suppliers to dispense a substitutable, premium-free medicine. The payment will be available only for PBS items which attract a Government subsidy. This includes PBS items supplied to DVA entitled consumers.
A number of conditions and criteria apply to receive this payment. Scripts will be assessed for validity and the Premium Free Dispensing Incentive payment will be paid by the Department of Human Services. Further information on this payment can be found on the Department of Human Services' website at: