Patient Charges for PBS Prescriptions: Example Calculations

Page last updated: 1 January 2020

The PBS co‑payment amounts and fees used in these examples are January 2020 values. These amounts and fees are indexed annually. In the examples, the general patient co‑payment is $41.00 and the concessional co‑payment is $6.60.

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

Setting:  approved PBS pharmacy

Prescription for famicin 100mg – 30 tablets

Dispensed Price for Maximum Quantity (DPMQ) for brand supplied = $41.40
DPMQ for base price brand = $36.20
Therefore, brand premium = $5.20

DPMQ for base price brand ≤ general patient co‑payment

  • prescription is under the general patient co‑payment amount

Formula for maximum total patient charge:

Step A.     DPMQ + Safety Net recording fee + Additional Patient Charge (capped at the amount of the general patient co‑payment if sum is greater)

Step B.     Add brand premium (if any)

Stepwise calculation

Step A.

  • DPMQ $36.20 + Safety Net recording fee of $1.25 = $37.45
    Subtotal is less than the maximum general co‑payment amount of $41.00 - no capping required.
  • $37.45 + additional patient charge of $4.60 = $42.05.

Sum of components is greater than the maximum general patient co-payment amount.
Charge is capped at general patient co‑payment of $41.00.
(the Additional Patient Charge component is limited to $3.55)

Step B.

  • $41.00 + $5.20 brand premium
    Maximum total patient charge = $46.20

For a PBS supply, the pharmacist may charge any amount up to $46.20.
If the amount charged is more than $46.20 – the prescription is considered non-PBS (the supply would be considered a private prescription and none of the amount paid would count towards the patient’s PBS Safety Net).

Formula for amount to Safety Net

DPMQ + Safety Net recording fee (capped at the maximum general patient co‑payment amount or capped at the amount charged if less than the co-payment amount)

Stepwise application

  • $36.20 + Safety Net recording fee of $1.25 = $37.45 (no capping required)

If amount charged is ≤ $46.20 and ≥ $37.45; the amount to Safety Net = $37.45
If amount charged is less than $37.45; the amount to Safety Net = amount charged.
If the amount charged is greater than $46.20; the prescription is non-PBS and the amount to Safety Net is Nil.

The Additional Patient Charge (up to $4.60) component does not count towards the Safety Net.
The brand premium does not count towards the Safety Net.

Example 1.2 - Under co-payment prescription – general patient

Setting:  approved PBS pharmacy

Prescription for ramaten 25mg – 28 capsules

DPMQ for brand supplied = $17.86
DPMQ for base price brand = $17.86

  • prescription is under co‑payment with no brand premium.

Formula for maximum total patient charge:

Step A.     DPMQ + Safety Net recording fee + Additional Patient Charge (capped at the amount of the general patient co‑payment if sum is greater)

Step B.     Add brand premium (if any)

Stepwise calculation

Step A.

  • DPMQ $17.86 + Safety Net recording fee $1.25 = $19.11

Subtotal is less than the maximum general co‑payment amount of $41.00 - no capping required.

  • $19.11 + additional patient charge $4.60 = $23.71 (no amounts reduced by capping).

The pharmacist can charge any amount up to $23.71.

Step B.

  • Not required as no brand premium.

Formula for amount to Safety Net
If amount charged is ≤ $23.71 and ≥ $19.11; amount to Safety Net = $19.11.
If amount charged is less than $19.11; amount to Safety Net = amount charged.
If the amount charged is greater than $23.71; 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

DPMQ for brand supplied = $45.80
DPMQ for base price brand = $42.40
Therefore, brand premium = $3.40

DPMQ for base price brand > maximum general patient co‑payment of $41.00

  •  prescription is over maximum co‑payment amount

For a prescription above the co‑payment amount, 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  a reduction up to $1 reduction)

Step B.     add price premium (if any)

Stepwise application

Step A.

  • The maximum general co‑payment amount of $41.00 (minus up to $1)

Step B.

  • $41.00 + $3.40 = $44.40 (minus up to $1)

The pharmacist can charge any amount from $43.40 to $44.40– but not less than $43.40 and not more than $44.40. Any other charge means the prescription is non‑PBS (the supply would be considered a private prescription and none of the amount paid would count towards the patient’s PBS Safety Net).

Formula for amount to Safety Net

If amount charged is an amount from $43.40 to $44.40,
the amount to Safety Net = $41.00.

If the amount charged is less than $43.40 or more than $44.40, the prescription is non-PBS and the amount to recorded against the patient’s Safety Net is Nil.