Pharmaceutical Benefits Scheme (PBS)

The PBS covers a wide range of medications listed in the schedule of pharmaceutical benefits.

If you’re a health or concession card holder, you may be entitled to receive further discounts on your PBS medication.² Along with your Medicare card, the following cards can offer you a further discount:

• Health care card
• Commonwealth Seniors Health Card
• Pensioner Concession Card
• DVA White, Gold or Orange Card
• PBS Safety Net Card.

Veterans can receive benefits under the Repatriation Pharmaceutical Benefits Scheme (RPBS).³ This provides access to some medications not available on the PBS.

Patient co-payment amount is the out-of-pocket expenses you’ll need to pay towards your PBS medicine.¹ This patient contribution is a set fee for all PBS items and the amount is updated annually on 1st January.

At the time of writing (September 2024), the co-payment prices are as follows:²

• General patient co-payment: $31.60
• Concessional co-payment: $7.70

Depending on the medicine, you may have the option to choose from several brands.¹ When this is the case, the government subsidises all brands to the same amount. This means that if you choose the more expensive brand, you’ll be paying the difference (in other words, an additional price on top of the co-payment). You may have heard of less expensive brands referred to as generic medications.

A difference in price doesn’t mean a difference in quality, and generic medications still need to meet all standards.¹ Sometimes, your doctor may be prescribing a specific brand for a reason, but in many cases, the generic brand will provide the same treatment.

The safety net is the extra support given to those who spend a significant amount on prescription medications.⁴ The threshold is the amount you need to spend in a calendar year before you’re eligible for these benefits. At the time of writing (September 2024), these thresholds are:

• General Patients: $1,647.40
• Concessional: $277.20

Once you’ve reached this amount, the price of your medication will drop.⁴ For general patients, all further PBS medication will be reduced to a concessional rate. For concessions, all PBS medication will be free of charge. These benefits last until the end of the calendar year.

Since September 2024, over 300 medicines have been available as 60-day prescriptions through the PBS.⁵ To be eligible for a 60-day prescription you must:

•     be living with an ongoing condition
•     have your current medication assessed
•     have talked with your doctor about your medicine
•     be provided with a 60-day prescription by your doctor.

Not all medications can be prescribed as a 60-day prescription. Even if your medication is eligible, your doctor may choose not to prescribe it as a 60-day prescription for various reasons (e.g. worries about side effects).

In most cases, non-PBS prescription medication will be covered by extras cover. The key exception is medication you receive while you’re an inpatient in a hospital, which will usually be covered as part of your hospital cover, provided you have cover for the surgery you’re receiving.

However, sometimes patients will be prescribed discharge medication to take once they’ve left the hospital (e.g. something to manage pain during recovery). As you’re not in the hospital anymore, this medication won’t be covered by your hospital cover. You may require extras cover to help pay for this medication.

Remember, just because the PBS doesn’t cover something doesn’t guarantee your policy will cover it. Your health fund will have inclusions and exclusions as to what they will cover, so be sure to check this when taking out a new policy.