4. Patient Charges
Page last updated: 01 January 2020
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 Services Australia.
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 Services Australia if they have enquiries about these arrangements.
PBS prescription forms supplied by Services Australia 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.
Under the PBS, the maximum cost for a pharmaceutical benefit item at a pharmacy is $41.00 for general patients and $6.60 for concession card holders, 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. Since 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 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’. Since 1 January 2016, expanded PBS early supply provisions replaced 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.
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 Services Australia. 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 Services Australia.
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 49' 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.
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.
For 'Regulation 49' 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 49 prescriptions are treated as a single supply. Usual Safety Net benefits apply for the entire supply if the interval between the Regulation 49 supply and the previous supply is greater than the specified period for the medicine. If the Regulation 49 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.
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.
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.