Patient Charges for PBS Prescriptions: Example Calculations

Page last updated: 29 August 2018

PBS co‑payment amounts and fees used in these examples are June 2018 values. These amounts and fees are indexed annually; in the examples, the general patient co‑payment is $39.50 and the concessional co‑payment is $6.40.

Example 1.1 - Under co-payment prescription with price premium – general patient

Setting:  approved PBS pharmacy

Prescription for famicin 100mg – 30 tablets

Commonwealth price for quantity for brand supplied = $41.40
Commonwealth price (dispensed base price for quantity) = $36.20
Therefore, brand premium = $5.20

Dispensed base price for quantity ≤ general patient co‑payment

  • prescription is under co‑payment

Formula for maximum total patient charge:
Step A.     Commonwealth price + Additional Fee + Additional Patient Charge (capped at the amount of the general patient co‑payment if sum is greater)

Step B.     Add price premium (if any)

Stepwise calculation

Step A.

  • $36.20 + additional fee of $1.21 = $37.41
    Subtotal is less than general co‑payment amount - no capping required.
  • $37.41 + additional patient charge of $4.45 = $41.86.

Sum of components is greater than general patient co-payment
Charge is capped at general patient co‑payment of $39.50
(the Additional Patient Charge component is limited to $2.09)

Step B.

  • $39.50 (capped) + $5.20 brand premium
    Maximum total patient charge = $44.70

Charging less than the maximum patient charge for this prescription
As a PBS supply, pharmacist may charge any amount up to $44.70.
If the amount charged is more than $44.70 – the prescription is non-PBS.

Formula for amount to Safety Net

Commonwealth price + Additional Fee (capped at the amount of the general patient co‑payment if sum is greater or capped at the amount charged if less)

Stepwise application

  • $36.20 + additional fee of $1.21 = $37.41 (no capping required)

If amount charged is ≤ $44.70 and ≥ $37.41; the amount to Safety Net = $37.41
If amount charged is less than $37.41; the amount to Safety Net = amount charged.
If the amount charged is greater than $44.70; the prescription is non-PBS and the amount to Safety Net is Nil.

The Additional Patient Charge component does not count to Safety Net.
The brand premium does not count to Safety Net.

Example 1.2 - Under co-payment prescription – general patient

Setting:  approved PBS pharmacy

Prescription for ramaten 25mg – 28 capsules

Commonwealth price for quantity for brand supplied = $17.86
Commonwealth price (dispensed base price for quantity) = $17.86

  • prescription is under co‑payment with no brand premium

Calculated maximum patient charge

  • Commonwealth price $17.86 + additional fee $1.21 = $19.07
    + additional patient charge $4.45 = $23.52 (no amounts reduced by capping)

The pharmacist can charge any amount up to $23.52.

Amount to Safety Net
If amount charged is ≤ $23.52 and ≥ $19.07; amount to Safety Net = $19.07.
If amount charged is less than $19.07; amount to Safety Net = amount charged.
If the amount charged is greater than $23.52; the prescription is non-PBS and the amount to Safety Net is Nil.

Example 2.1 - Over co-payment prescription with brand premium – general patient

Setting:  approved PBS pharmacy

Prescription for natamicin 500mg – 100 tablets

Commonwealth price for quantity for brand supplied = $45.80
Commonwealth price (dispensed base price for quantity) = $42.40
Therefore, brand premium = $3.40

Dispensed base price for quantity > general patient co‑payment

  •      prescription is over co‑payment

For an over co‑payment prescription, the pharmacist may elect to reduce the co‑payment amount by up to $1.

Formula for maximum total patient charge:

Step A.     general patient co‑payment (with or without up to $1 reduction)

Step B.     add price premium (if any)

Adding the brand premium is required for an over co‑payment PBS prescription. (A brand premium is optional only if the prescription is under co‑payment.)

Calculated patient charge

  • $39.50 + $3.40 = $42.90
    or ($39.50 minus up to $1) + $3.40 = not less than $41.90

The pharmacist can charge any amount from $41.90 to $42.90 – but not less than $41.90 and not more than $42.90. Any other charge means the prescription is non‑PBS, non‑claimable and does not count to Safety Net.

Amount to Safety Net

If amount charged is an amount from $41.90 to $42.90,
the amount to Safety Net = $39.50.

If the amount charged is less than $41.90 or more than $42.90, the prescription is non-PBS and the amount to Safety Net is Nil.