Patient Charges for PBS Prescriptions: Example Calculations
Page last updated: 1 January 2023
The Pharmaceutical Benefits Scheme (PBS) co‑payment amounts and fees used in these examples are based on the fees and mark-ups from 1 January 2023. These amounts and fees are indexed annually. In the examples, the general patient co‑payment amount is $30.00 and the concessional co‑payment amount is $7.30. Please note that the drug names in the example calculations are fictitious.
Example 1.1 - Under co-payment prescription with brand premium – general patient
Setting: approved PBS community pharmacy
Prescription for famicin 100mg – 30 tablets
Dispensed Price for Maximum Quantity (DPMQ) for brand supplied = $32.60
DPMQ for base price brand = $27.40
Therefore, brand premium = $5.20
DPMQ for base price brand ($27.40) ≤ general patient co‑payment amount ($30.00)
DPMQ for base price brand ≤ general patient co‑payment amount
- prescription is under the general patient co‑payment amount
Formula for maximum total patient charge:
Step A. DPMQ (for base price) + Safety Net recording fee + Additional Patient Charge (capped at the amount of the general patient co‑payment amount if sum is greater)
Step B. Add brand premium (if any)
Stepwise calculation
Step A.
- DPMQ $27.40 + Safety Net recording fee of $1.31 = $28.71 Subtotal is less than the general co‑payment amount of $30.00, therefore no capping required.
- $28.71 + additional patient charge of $3.29 = $32.00
Sum of components is greater than the maximum general patient co-payment amount.
Charge is capped at general patient co‑payment amount of $30.00.
The Additional Patient Charge component is limited to $1.29 ($30.00 - $28.71).
Step B.
-
$30.00 + $5.20 brand premium
Maximum total patient charge = $35.20
For a PBS supply in this example, the pharmacist may charge any amount up to $35.20. If the amount charged is more than $35.20, the prescription is considered a non-PBS prescription (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
-
$27.40 + Safety Net recording fee of $1.31 = $28.71 (no capping required)
If amount charged is ≥ $28.71 and ≤ $35.20; the amount towards the Safety Net = $28.71
If amount charged is less than $28.71; the amount to Safety Net = amount charged.
If the amount charged is greater than $35.20; the prescription is non-PBS and the amount that counts towards the Safety Net is nil
The Additional Patient Charge (up to $3.29) 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 community pharmacy
Prescription for ramaten 25mg – 28 capsules
DPMQ for brand supplied = $17.86
DPMQ for base price brand = $17.86
- prescription is under the general co‑payment amount 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 amount if sum is greater)
Step B. Add brand premium (if any)
Stepwise calculation
Step A.
- DPMQ $17.86 + Safety Net recording fee $1.31 = $19.17
- Subtotal is less than the maximum general co‑payment amount of $30.00 - no capping required.
- $19.17 + additional patient charge $3.29 = $22.46 (no amounts reduced by capping).
The pharmacist can charge any amount up to $22.46.
Step B.
- Not required as no brand premium.
Formula for amount to Safety Net
If amount charged is ≥ $19.17 and ≤ $22.46; amount to Safety Net = $19.17.
If amount charged is less than $19.17; amount to Safety Net = amount charged.
If the amount charged is greater than $22.46; the prescription is non-PBS and the
amount that counts towards the Safety Net is nil.
Example 2.1 - Over co-payment prescription with brand premium – general patient
Setting: approved PBS community pharmacy
Prescription for natamicin 500mg – 100 tablets
DPMQ for brand supplied = $47.00
DPMQ for base price brand = $43.60
Therefore, brand premium = $3.40
DPMQ for base price brand ($43.60) > maximum general patient co‑payment amount ($30.00)
- prescription is over the general co‑payment amount
For a prescription with a DPMQ above the co‑payment amount, the pharmacist may elect to reduce the co‑payment amount by up to $1.00.
Formula for maximum total patient charge:
Step A. general patient co‑payment amount (with or without a reduction up to $1.00 reduction)
Step B. add price premium (if any)
Stepwise application
Step A.
- The maximum general co‑payment amount of $30.00 (minus up to $1.00)
Step B.
- $30.00 + $3.40 = $33.40 (minus up to $1.00)
The pharmacist can charge any amount from $32.40 to $33.40 – but not less than $32.40 and not more than $33.40. 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 $32.40 to $33.40, the amount to Safety Net = $30.00.
If the amount charged is less than $32.40 or more than $33.40, the prescription is non-PBS and the amount to recorded against the patient’s Safety Net is Nil.