Pharmaceutical Benefits Scheme (PBS) patient refunds 011-60020000

Section 87A of the National Health Act 1953 sets out the circumstances in which a person is entitled to claim a refund for PBS medicines from Services Australia.

A patient can request a PBS patient refund for the following reasons:

• Over the PBS Safety Net threshold - the patient/family exceeded the annual general or concessional PBS Safety Net threshold
• Medicare or Concession card not shown (No-card) - the patient paid a higher co-payment for their prescription for not showing a Medicare card or concession card at the pharmacy. Note: The pharmacy may charge allowable additional fees and premiums that are not refundable.
• Closing The Gap (CTG) - a patient entitled to the reduced CTG co-payment and registered under the CTG - PBS Co-payment Program did not get a reduced co-payment applied when the script was dispensed

Refunds are paid by EFTPOS to the claimant’s bank account details registered for Medicare.

Services Australia can only pay refunds for PBS items supplied through approved PBS suppliers.

Submitting patient refund

Claimants submit a refund by completing the PBS Patient claim for refund form (PB132) available to download and print on the Services Australia website. The appropriate supporting documents must be included in the claim.

PBS patient refund claims can be submitted at a Service Centre, or by post. There is no electronic option for submission of patient refund claims.

Supporting documents required for a patient refund

The type of supporting document submitted for a patient refund will depend on the type of refund being claimed. The pharmacist must sign all supporting documents.

Prescription record forms (PRFs) - Over-the-threshold patient refunds
Prescription Record Forms (PRFs) are generated by pharmacy dispensing software. Patients can also download a PBS/RPBS Safety Net prescription record form (PB240) from the Services Australia website to keep a record of how much they spend on RPBS/PBS medicines

Pharmacy receipts - No-card and CTG refunds
S87A Pharmacy receipts:

• show the:
• patient details
• date of supply
• PBS item code
• quantity supplied
• amount paid by the patient, and
• must be signed by the pharmacist

No-card refund claims for scripts dispensed privately may also need a copy of the original/duplicate prescription to determine if the script is eligible for a PBS refund.

Tax invoice or patient history report
In addition to S87A pharmacy receipts and Prescription Record Forms (PRFs), a tax invoice or patient history report can also be accepted if they have been endorsed as:

• paid in full, and
• signed by the pharmacist, and
• include all relevant information required to process a patient refund

The pharmacy tax invoice or patient history report will show the amount paid which may include additional fees and premiums. The details on the pharmacy tax invoice may be:

• enough to claim a no-card refund, ,but
• not enough to claim an over the threshold refund

Documents that cannot be accepted for a patient refund

The following documents are not accepted for a patient refund:

• A pharmacy account or statement of account
• The pharmacy cash register/EFTPOS docket
• A PRF where the pharmacy has added items supplied at other pharmacies to their own computer generated PRF

Calculating the refundable amount

Section 87A of the National Health Act 1953 states the refundable amount is the difference between the patient's contribution and the Commonwealth dispensed price, as listed in the Schedule of Pharmaceutical Benefits.

There are additional fees and charges that may be applied to prescriptions that are not refundable:

• Allowable extra fees
• Brand price premium
• Therapeutic group premium
• Special patient contribution (SPC)

For this reason, the difference between the amount paid and the amount refunded may be greater, resulting in the claimant being refunded less than they expected.

Visitors from Reciprocal Health Care Agreement (RHCA) countries may or may not be issued a Medicare card.

All eligible visitors covered under the RHCA are entitled to patient refunds for valid PBS prescriptions except for section 100 In-Vitro Fertilisation medicines.

POA, Guardianship and Administration Orders give people the authority to act on behalf of another individual and can vary on a case-by-case basis. Each patient refund claim made by a claimant with this legal authority will be considered to determine whether they are allowed to claim on behalf of another individual.

Note: Services Australia is required to either sight the original POA, Guardianship or Administration Order documents or a certified copy of the original documents.