The department administers two schemes that provide subsidised access to medicines:

• the PBS
• the RPBS.

The PBS provides subsidised access to a wide range of medicines for Australian residents and eligible overseas visitors.

The RPBS gives eligible veterans and their eligible widows, widowers and dependants subsidised access to some additional medicines and dressings at concession rates. If it is clinically justified, the RPBS also subsidises items that are not listed on either the PBS or RPBS schedules.

In administering these schemes, the department processes requests for approval from prescribers for medicines that require prior authority to access the PBS subsidy. The department also processes approved supplier claims for the supply of PBS and RPBS medicines to eligible customers.

Table 18: PBS and RPBS expenditure

PBS eligibility

The price paid for PBS medicines depends on a person’s level of eligibility and whether the approved supplier provides up to the optional maximum $1 co‑payment discount that took effect from 1 January 2016. The two levels of eligibility are the general rate and the concession rate.

The PBS general and concession rates are adjusted on 1 January each year in line with the consumer price index.

The maximum cost for a pharmaceutical benefit item at the general rate from 1 January 2019 is $40.30. All Australian residents and eligible overseas visitors can access PBS medicines at the general rate.

Patients and their families with a valid concession card from the department or DVA are eligible for the concession rate of $6.50 maximum cost for a pharmaceutical benefit item.

Patients may pay extra for more expensive brands of medicines.

PBS Safety Net

The PBS Safety Net helps patients with the cost of their medicines when they or their families require a large number of prescription medicines in a calendar year.

The PBS Safety Net thresholds were adjusted from 1 January 2019 in line with the consumer price index. The 2019 general threshold is $1,550.70, and for concession cardholders the threshold is $390.00. After patients reach the relevant threshold, a pharmacist can issue them and their family members covered by the scheme a PBS Safety Net card. Their contribution for PBS medicines for the rest of the calendar year will then be:

• $6.50 for general patients
• nil for concession cardholders.

Patients may pay extra if prescription repeats are filled too close together.

Indigenous people’s access to the PBS

The department administers special PBS arrangements in remote Indigenous communities through Aboriginal Health Services and some state and territory funded health services. Patients of approved remote area Aboriginal Health Services can access PBS medicines directly from these services at no cost.

At 30 June 2019, there were 166 approved Aboriginal Health Services around the country.

Aboriginal and Torres Strait Islander people living with chronic disease, or at risk of it, can also receive assistance with the cost of PBS medicines through the Closing the Gap PBS Co‑Payment measure. Since 1 July 2010, eligible patients have received free PBS medicines or medicines at the concession patient contribution rate.

Travelling with PBS medicines

Under the National Health Act 1953, it is illegal to take or send PBS subsidised medicines out of Australia unless they are for the personal use of the person to whom the medicine was prescribed.

The Pharmaceutical Benefits Scheme—Taking or Sending Medicine Overseas enquiry line and the department’s website provide information and advice to people about their responsibilities and rights when travelling overseas with PBS medicines.

In 2018–19, the enquiry line received more than 2,000 calls and the Travelling Overseas with PBS Medicine web page received 37,498 visits.

Online claiming for the PBS

Online claiming for the PBS allows approved suppliers to lodge prescription claims with the department each time a PBS or RPBS medicine is dispensed. At 30 June 2019, 99.9 per cent of approved suppliers of PBS and RPBS medicines used online claiming.

Authority-required prescriptions

The Schedule of Pharmaceutical Benefits lists authority‑required PBS medicines. Some of these medicines need prior approval from the department before they can be prescribed to patients. These medicines are for the treatment of specific conditions.

In 2018–19, 6.3 million authority approval requests were received. (Note: Figures include RPBS authority approval requests administered by DVA of 0.3 million.)

The department provides online capability for approved prescribers to get a PBS authority approval through HPOS or via prescribing software. This removes the need for prescribers to phone the department for most authority approvals.

Prescription Shopping Programme

The Prescription Shopping Programme helps prescribers to identify patients who get more PBS subsidised medicines than they medically need. It also provides information to help prescribers make informed prescribing decisions and better manage the health outcomes of their patients.

We administer the program on behalf of the Department of Health in accordance with the Human Services (Medicare) Regulations 2017.

The program has two components:

• the Prescription Shopping Information Service
• the Prescription Shopping Alert Service.

The Prescription Shopping Information Service is a 24‑hour phone line available to prescribers and approved suppliers. The Prescription Shopping Alert Service assesses patients who meet the program’s criteria each month, and writes to prescribers whose patients may be obtaining more medicines than they medically need.