Processing an existing Authority request in the Pharmaceutical Benefits Scheme (PBS) 012-63020020

Requests defined as too soon can be approved without Pharmaceutical Adviser (PA) referral only where:

• all other approval requirements for the item are met, and
• approval and supply history checks are completed

Some authorities may return a too soon date within 24-48 hours.

Do not automatically override these applications, because, it is only one or 2 days away, this means the patient has 30 or 60 days on hand including the one or 2 days.

Acceptable too soon situations without PA escalation include:

• where a manual calculation indicates that it is not ‘too soon’ for another approval
• once off lost, stolen or destroyed scripts/medication
• quantity/repeats dispensed is less than approved
• dose adjustment (increase or decrease)
• additional strength (different PBS item code) of the same medication is required
• incorrect dose/quantity/repeats keyed into system
• discharge prescription from a PBS reformed public hospital (up to one month)
• unable to access previous scripts due to moving to/from residential care or private hospitals
• previous authority not fully dispensed, where:
• prescription has expired due to state/territory legislation
• patient has changed pharmacy and requirement for previous pharmacy to retain repeat
• travelling (approve for duration of travel only)
• except for opioids and alprazolam
• this includes Section 49 (previously Regulation 24)
• specialist scripts (the patient may see the specialist infrequently due to accessibility) - except for opioids and stimulants

When to perform a manual calculation to determine too soon:

• if a prescriber disputes the too soon result returned from the OPA System
• reason code 805 displays, ‘Too Soon has previously been overridden for a related application’. This means a too soon check was not performed by OPA
• while processing a written application, reason code 095 displays, ‘This patient should have more than 30 days' supply available from prior authority/s. Next request can be made from <>. 1 or more previously approved authorities are yet to be supplied’. Check the Authority History comments for lost/cancelled scripts and blocked repeats

Do a manual calculation using the Authority Approval history in the Patient History function before:

• escalating to a Pharmaceutical Adviser (PA)
• changing the OPA assessment result

Dispensing history check may also be required, depending on the scenario.

For:

• Telephone authority requests, go to Step 2
• Written authority requests, go to Step 3

Advise the prescriber the patient has more than a 30 or 60 day supply on hand (depending on the item):

• do not release the earliest assessment date to the prescriber
• do not automatically override these applications, for example: it is only one or 2 days away, this means the patient has 30 or 60 days on hand including the one or 2 days

If the provider provides an acceptable 'too soon' reason or an extenuating circumstance:

• confirm the details. If:
• verified and the rejection can be overridden, go to Step 5
• not verified, escalate to LPS

If the prescriber disagrees with the OPA assessment, escalate to a Pharmaceutical Adviser (PA).

If the prescriber accepts the medication is 'too soon', procedure ends here.

Before rejecting a written authority for too soon, perform a manual calculation using the Patient History function. Go to Step 4.

To review the patient history:

• select Patient History from the:
• patient’s name Hyperlink, or
• Patient History button in the expanded top panel
• select the collapsed view of the authority
• Assessment Results in bold should be in the manual history, check:
• 1 = Approved
• 2 = Approved with changes
• 3 = Rejected
• 4 = Pended/ Saved
• 5 = Previously rejected / now approved
• 6 = Authority not required
• D = Duplicated
• C = Cancelled
• E = Re-Issued
• W = Awaiting Assessment
• use the Authority History to perform a manual calculation for too soon (not the dispensing history)
• calculate the past 6 months of authority approval history
• use the Too soon calculator (New) to check how long the previous supply should last

When assessing too soon, the OPA System:

• performs a consistent approach to all too soon checking
• starts the assessment from the most recent approval and works back
• stops assessing once the first instance of too soon is found
• uses up to 12 months of history to calculate too soon
• considers if any previous too soon rejections have been overridden
• considers if the original has been supplied from previous approvals
• does not take into consideration:
• any undispensed repeats
• dose changes
• any blocked repeats
• does not include prescriptions for non-authority or streamlined quantities or repeats that may appear on the patients dispensing history (these supplies can be included when completing a manual calculation)

Note: the way OPA system calculates too soon may not return the same result as a manual calculation.

Has the Manual calculation results confirmed the request is too soon?

• Yes. For:
• Telephone Authority, tell the prescriber the history has been confirmed, and the application is not approvable (unless there was extenuating circumstances or an acceptable explanation is provided)
• Written Authority/ HPOS form upload. If the Authority cannot be approved, reject the application. The supply should last until the date determined by the manual calculation. Generate a rejection letter and HPOS response for HPOS Form upload requests. Use the patient history to calculate the date they can apply from, and include this in the rejection letter
• No:
• override and approve
• select Assessment Result Override option
• Add Authority comment with the reason for the override of too soon rejections, select save comments
• Telephone Authority provide the authority approval details to the prescriber, procedure ends here
• Written Authority generate an approval letter for post or a HPOS response to return to the prescriber. Go to Table 4 in Processing new Authority requests in the Pharmaceutical Benefits Scheme (PBS).

Select Approved from the Assessment Result Override dropdown:

• select an appropriate reason from the Override Reason dropdown
• override the authority assessment
• select Back to add an Authority Comment
• select Save Comments. The comments help to assess if future too soon rejections are:
• once-off, or
• recurring issues
• if the prescriber indicates that the too soon rejection has occurred because a specific authority approval in the patient's history is no longer available, for example lost, stolen/destroyed. Locate the previous authority using the Patient History function

If the authority was from:

• the same prescriber but not yet supplied (Original Supply column is N or blank), see Table 2 to locate the authority:
• Override the assessment result to Rejected to prevent the authority from being used in the future
• the same prescriber, but the original authority has already been supplied (Original Supply column is Y):
• use the patient's Dispensing History in the Patient's History tab to determine how many supplies have already been made. Include this number in the Authority Comment on the current authority. If the prescriber requests outstanding repeats to be cancelled, the Block function can be used. See Table 4
• a different prescriber, no further action is required

To:

• cancel the authority, go to Step 2
• amend the authority, go to Step 3
• update Authority Approval Number post assessment, go to Step 5
• re-Issue the authority, go to Step 7

Approved prescribers who requested the authority record can ask for it to be cancelled if supply has not been made.

In the Search Results, select Amend next to the relevant record:

• Assessment Result is Approved, Approved with Changes or Previously rejected/now approved, select View Result Details on the Authority Summary screen
• in the Assessment Result Override panel select Rejected from the dropdown
• in the Override Authority pop-up, select Other and add a comment explaining the reason for the cancellation
• the Application Assessment Result screen will show with an Assessment Result of Rejected
• staff must add an Authority Comment on the Authority summary screen. Go to Table 6 in Processing new Authority requests in the Pharmaceutical Benefits Scheme (PBS).
• procedure ends here

Authority records that need:

• information changed to meet PBS restriction, or
• to correct a keying error on a Written Authority application
• go to Step 4

Authority records being:

• replaced because of issues with the previous prescription
• amended as an authority prescription number post assessment
• go to Step 5

Check the authority application and, if supplied, the prescription and supporting documents to see if the new information meets the PBS criteria:

• in the Search Results, select Amend next to the relevant record
• select the Edit button next to the field to be amended on the Authority summary screen
• key in the correct information

To clarify restriction intent, refer to a Pharmaceutical Adviser (PA) who provides information on how to proceed.

If PA is unavailable, follow the Pharmaceutical Adviser Escalation process:

• complete either a General Authorities PA or Complex Drugs PA call back form
• for Telephone Authority advise the caller that the issue will be referred to a Pharmaceutical Adviser

Prescriber Details, Date of Prescribing, Date of lodgement or Patient Details:

• select Edit from the top panel
• amend the details > Search > Return

Prescription Details (Dose, Frequency, Quantity or Repeats):

• select Edit
• amend the details > Return

Changing the Selected PBS Item or Selected restriction:

• select Edit
• amend the details > Next
• information on subsequent screens must be entered

Changing the Questions & Answers:

• expand the Questions & Answers section > Edit
• amend the details > Next

For:

• Telephone, see Table 2 > Step 16 in Processing new Authority requests in the Pharmaceutical Benefits Scheme (PBS).
• Written Authority requests, see Table 2 > Step 16 in Processing new Authority requests in the Pharmaceutical Benefits Scheme (PBS).

Note: if the previous assessment result was Approved, the new assessment result shows as Approved with Changes. A new approval number is generated. Previous approval numbers are linked to the current version. Select View Previous Version from the Authority Summary screen.

To update:

• confirm the following details:
• patient's name
• date of prescribing
• prescriber number
• medication prescribed-form and strength
• over-key the Authority Prescription Number on the Authority Summary screen > Submit
• the original authority record changes to an Assessment Result of Rejected and can only be viewed using the View Previous Version button
• the updated Authority Prescription Number shows as the active approved version of the authority

Service Officers are not required to amend the previous record to Duplicate.

Generate a replacement approval if a previously approved Authority can no longer be used.

• if the authority prescription number was incorrectly entered and has not been supplied, go to Step 5
• if the same approved prescriber did not request the previous prescription, escalate to a Pharmaceutical Adviser (PA) who will provide information on how to proceed
• if a PA is unavailable, follow the escalation procedure. Procedure ends here.

If the authority request being replaced has been dispensed, do not change the assessment result. Service Officers can:

• replace the repeats that have not been dispensed (use balance of supply restriction if available)
• request the remaining repeats are destroyed
• use the block function to prevent the remaining repeats being dispensed. See Table 4 for blocking and unblocking

Only suitably skilled Service Officers trained in using the re-issue function, can use the re-issue function.

The re-issue function can only be used for s100 Growth Hormone paediatric items. The re-issue can be used to generate a replacement authority based on the item, quantity & repeats, restriction and Authority Required Logic System/Complex Criteria screen that were given previously.

Note: the date of prescribing on a re-issued authority must be the same as the date of prescribing on the authority being replaced and cannot be amended.

To re-issue an authority:

• select Search Authorities
• key the Medicare card number
• from the search results list, select Re-Issue for the relevant authority
• key the new Authority Prescription Number
• if required, amend the Weekly Dose, Prescribed Quantity and/or Prescribed Repeats
• select the reason from the Reason For Re-Issue dropdown
• select Re-Issue
• read the approval number to the prescriber for phone applications

If an approved prescriber is calling for further information on an Authority request:

• locate the authority in OPA
• select View Result Details

Access the PBS Reason Code Maintenance System via Medicare e-Business Gateway:

• key the 3 digit Reason Code located on the application assessment screen in OPA and select Search
• select the Automated PBS Authorities search result
• follow the Fix Instructions for Approved Prescribers and/or Operator Instruction Text to help resolve the reason code
• escalate to a Local Peer Support (LPS) if the enquiry cannot be resolved at first point of contact

The Resources page includes information on the Services Australia website to help Approved prescribers access and use the Online PBS Authorities system.

To block, go to step 2

Unblocking a blocked authority

Approved prescribers must call to have an authority unblocked.

Locate the authority.

If the approved prescriber is different, go to Step 3

If the approved prescriber is the same:

• select View
• add an Authority Comment with the reason the prescription is being unblocked on the Authority Summary screen
• select Unblock for the Unblock Authority popup
• select Yes to unblock
• procedure ends here

A prescriber can request that an already supplied prescription be blocked, preventing further supply of any remaining repeats on that prescription. Only the prescriber who wrote the prescription is authorised to request to block or unblock a prescription:

• blocking a prescription does not occur immediately. Supplied authorities that have a status of Approved, Approved with Changes or Previously rejected now approved, will take effect the day after the block was actioned
• OPA shows the active block date
• Service Officers can unblock an authority from View mode
• if the physical prescription is still available, it may still be dispensed privately and Services Australia cannot prevent this

Locate the authority, and:

• check Patient History
• if the block request is for same approved prescriber who requested the authority and the authority has not been supplied, go to Table 2 > Step 2

Is the approved prescriber the same?

• Yes:
• select View
• add an Authority Comment providing the reason the prescription is being blocked
• select Block for the Block Authority-Confirmation popup
• select Yes to block the further supply of remaining authority repeats
• when blocked, the block date shows under the selected PBS item section
• procedure ends here
• No:
• the approved prescriber is different, do not block the authority
• go to Step 3

If the approved prescriber is different and is requesting to block the repeats:

• do not block the remaining repeats
• add an Authority Comment to the OPA record for which blocking was requested, outlining the reason for the block request
• tell the approved prescriber we are unable to do this. If possible, they must destroy the physical prescription
• procedure ends here

If the approved prescriber is different and requesting to unblock the repeats:

• explain this cannot be done, and
• offer a new approval if the patient meets PBS requirements, if the prescriber requests a new approval, follow the process in Processing new Authority requests in the Pharmaceutical Benefits Scheme (PBS)

• if the prescriber does not request a new approval, procedure ends here

Locating the Authority in PBS Authority Systems OPA.

Select the correct prescription and click on Amend.

If the prescription is:

• requested by the same approved prescriber, go to Step 4
• not requested by the same approved prescriber, go to Step 3

Refer to LPS if enquiry is regarding a process, LPS will provide information on how to proceed.

If LPS is unavailable

• follow the Tier 0 technical support - self-sufficiency, and
• complete the LPS Referral Form

Refer to a PA for pharmaceutical enquiry, the PA will provide information on how to proceed. If a PA is unavailable, follow:

• the Pharmaceutical Adviser Escalation process
• complete either a General Authorities PA or Complex Drugs PA callback form
• advise the caller that the issue will be referred to a PA

Search authorities in OPA to check the supply date.

Has the prescription been dispensed?

• Yes, refer to Local Peer Support/Pharmaceutical Adviser Escalation procedures
• No, go to Step 5

If the prescription has not yet been dispensed, the assessment result can be changed from the previous approval to Duplicate:

• select Amend, view result details
• select assessment result override to change approval to Duplicate
• key an Authority comment providing details why the prescription is not valid

Note: if unable to Amend, this means the prescription has been dispensed by the pharmacy.

For returned:

• assessment letters, go to Step 2
• original prescriptions, go to Step 4
• streamlined approved Authority prescription inadvertently received, see Authority required (STREAMLINED) items in the Pharmaceutical Benefits Scheme (PBS).
  Procedure ends here.

Check the prescriber's address on the assessment letter matches original authority request in Work Optimiser, see Table 2 > Step 2

If the address:

• does not match, generate a new envelope
• matches, contact the prescriber for the correct address details to forward the assessment letter. If requested by the approved prescriber, staff can provide the:
• approval number if the authority has been approved, or
• rejection reason
• matches and the prescriber’s contact details on the authority request are outdated, go to Step 3

Log into the Medicare Portal - eBusiness Gateway:

• from the dropdown menu, select the PDS > Submit
• from the Provider Directories, open Provider > View > Basic search
• from the ID Type dropdown menu, select Prescriber Number
• key the prescriber number in the Search ID field > Search. If the prescriber number is missing and the prescriber is a Medical Practitioner:
• from the Provider Directories open Provider > View > Detailed Search
• key Family Name > Given Name > Profession
• select Area of Registration > Search

Have the prescriber’s details been located:

• Yes:
• Contact details are recorded, call the prescriber and clarify address details
• No contact details recorded, enter an Authority comment RTS in OPA, prescriber details not recorded in PDS
• Procedure ends here
• No:
• Enter RTS in the Authority comment field in OPA, unable to find prescriber contact details
• Procedure ends here

For inadvertently received approved prescriptions, check the paper prescription details.

If the approved prescriber has endorsed an approval number (for example, M9999RX) on the prescription, but has sent the prescription to Services Australia, and the prescription does not require further approval, locate and view the authority:

• access Authorities System (OPA), locate the authority, see Table 2
• confirm the prescription details match the entry in OPA
• generate letter Already approved authority prescription
• key the date the authority was approved in the Authority comment field

Go to Step 5.

In the Authority comments, key:

• RTS - what action has been taken, for example:
• Rx now forwarded to prescriber
• Incorrect address on envelope, resent to prescriber
• add Service Officer P-number or log-on > Save