Knowledge Base

Background:

To support the Discounting PBS Patient Co-payment measure s90 approved suppliers (Retail pharmacy) will be:

• able to offer a discount of up to $1.00 on the patient co-payment for PBS and RPBS prescriptions; and
  
• the actual amount paid by a patient and the discount amount, if any, applied to a PBS or RPBS prescription is to be provided as part of the PBS Claim record
  

• A new PBS Actual Contribution field to indicate the actual amount paid by the patient.
  
• A new PBS Discount Contribution field to indicate the actual discount given by the pharmacy.
  

NOTE:  S94 approved suppliers (Public and Private hospital pharmacies) will be required to ONLY provide the actual amount paid by a patient for a PBS/RPBS prescription priced below the co-payment.

The PBS Co-Pay discount is set against a patient category. In the Patient Category screen, you can set the PBS Co-Pay discount amount not exceeding $1.00 for concession patients (field 22) and general patients (field 23). Field 15: Hospital must also be set to “N” to indicate that scripts dispensed under this patient category DO NOT originate from the hospital.

NOTE: For S94 public and private hospital patient categories, field 22 and field 23 must be set to $0.00.

The patient charge field (Field 17) in the dispense screen will be the (PBS price to consumer) minus the (pbs co-pay discount set in field 22/23 against the patient category).  The patient charge field (Field 17) value will be used to populate the new “PBS Actual Contribution” data element in the PBS claim message.

 NOTE:

• The PBS patient co-payment cannot be discounted for prescriptions dispensed under the Safety Net 20 day rule. Therefore, the patient charge field (Field 17) in the dispense screen will be the (PBS price to consumer)
  
• The co-payment for a prescription endorsed as Regulation 24 can be discounted. Therefore, the patient charge field (Field 17) in the dispense screen will be the (PBS price to consumer) minus the (pbs co-pay discount set in field 22/23 against the patient category) multiplied by (number of repeats and original supplied).
  
• The Merlin estimated PBS rebate will be the (PBS dispense price) minus (PBS price to consumer) exclusive of the (pbs co-pay discount set in field 22/23 against the patient category), which should align with the actual PBS rebate.
  
• An eligible discounted co-payment can accrue to the patient’s safety net. The “actual co-payment amount paid by the patient” (i.e. patient charge field (Field 17) in the dispense screen) is recorded on the patient’s Prescription Record Form.