Patient Charges for PBS Prescriptions: Example Calculations

Page last updated: 1 January 2024

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 2024. These amounts and fees are indexed annually. In the examples, the general patient co‑payment amount is $31.60 and the concessional co‑payment amount is $7.70. 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 ($31.60)

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 $1.40 = $28.80 Subtotal is less than the general co‑payment amount of $31.60, therefore no capping required.
• $28.80 + additional patient charge of $3.45 = $32.25

Sum of components is greater than the maximum general patient co-payment amount.
Charge is capped at general patient co‑payment amount of $31.60.
The Additional Patient Charge component is limited to $2.80 ($31.60 - $28.80).

Step B.

• $31.60 + $5.20 brand premium
  Maximum total patient charge = $36.80

For a PBS supply in this example, the pharmacist may charge any amount up to $36.80. If the amount charged is more than $36.80, 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 $1.40 = $28.80 (no capping required)

  If amount charged is ≥ $28.80 and ≤ $36.80; the amount towards the Safety Net = $28.80
  If amount charged is less than $28.80; the amount to Safety Net = amount charged.
  If the amount charged is greater than $36.80; the prescription is non-PBS and the amount that counts towards the Safety Net is nil

The Additional Patient Charge (up to $3.45) 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 $1.40 = $19.26
• Subtotal is less than the maximum general co‑payment amount of $31.60 - no capping required.
• $19.26 + additional patient charge $3.45 = $22.71 (no amounts reduced by capping)

 

The pharmacist can charge any amount up to $22.71.

Step B.

• Not required as no brand premium.

Formula for amount to Safety Net

If amount charged is ≥ $19.26 and ≤ $22.71; amount to Safety Net = $19.26.
If amount charged is less than $19.26; amount to Safety Net = amount charged.
If the amount charged is greater than $22.71; 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 = $57.00
DPMQ for base price brand = $53.60
Therefore, brand premium = $3.40

DPMQ for base price brand ($53.60) > maximum general patient co‑payment amount ($31.60)

•  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 $31.60 (minus up to $1.00)

Step B.

• $31.60 + $3.40 = $35.00 (minus up to $1.00)

The pharmacist can charge any amount from $34.00 to $35.00 – but not less than $34.00 and not more than $35.00. 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 $34.00 to $35.00, the amount to Safety Net = $31.60.

If the amount charged is less than $34.00 or more than $35.00, the prescription is non-PBS and the amount to recorded against the patient’s Safety Net is Nil.