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Everything You Need to Know about PBS and non-PBS Pharmaceuticals

Megan Fraser
Megan Fraser Updated: 28 April 2021
Types of Health Insurance

Everything You Need to Know about PBS and non-PBS Pharmaceuticals

Medications help treat and prevent various ailments but can be costly. Australia’s Pharmaceutical Benefits Scheme (PBS) affords its residents support with the cost of several prescription medications dispensed by pharmacists. Thereby ensuring parents can access the medication they need without being faced with excessive out-of-pocket costs.

Here’s more information about what PBS offers, who benefits from the scheme and how you can get the medication you need cost-effectively.

Key Facts

  • The Pharmaceutical Benefits Scheme provides affordable access to medications.
  • To qualify for the PBS, you’ll need a current Medicare card or be visiting from a country with a reciprocal health care agreement.
  • If you’ve reached the PBS threshold, you can work towards the Safety-net threshold.
  • To use your PBS benefits, you’ll need a valid prescription from a health care professional.

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What is the pharmaceutical benefits scheme (PBS)?

The Australian Government introduced a program in 1948 to provide access to affordable medication for everyone with a Medicare card and those visiting from countries with a Reciprocal Health Care Agreement (RHCA). The purpose of the PBS is to provide you with reliable, timely and affordable access to prescription medicines.

Who is eligible for PBS?

All Australians and concession cardholders who have a current Medicare card are eligible to receive PBS medication by prescription. However, those visiting from a country with a Reciprocal Health Care Agreement may also qualify for the Pharmaceutical Benefits Scheme and receive subsidised medications.

Generally, one of the following health care cards are accepted:

  • Concession Pensioner Card
  • Commonwealth Seniors Health Card
  • A Health Care Card
  • Department of Veterans Affairs White, Gold, or Orange Card

Take note: Sometimes, you might not qualify for the subsidy due to other factors, for example, your age, gender, health and medical history. It’s important to confirm your qualification with your medical practitioner when they write you a prescription.

What does the Pharmaceutical Benefits Scheme cover?

In Australia, prescriptions are generally divided into two categories:

pbs list

PBS Medications

Medications covered can be found on the PBS website. A comprehensive list of generic medications is available and is updated on the first day of each month. If you claim medicines from this list, the Government’s subsidised portion is typically paid directly to the pharmacy.

non pbs list

Non-PBS Medication

If the medicine you need is not listed under the PBS, you’ll generally have to pay full price. A private health insurance policy may allow you to claim a benefit for non-PBS medication. It’s generally a good idea to compare policies to find cover that pays for your medications if you require chronic medications.

What is the PBS safety net?

This is a mechanism that ensures that people who spend more than a threshold amount on medicines in a year can get cheaper or even free medication for the remainder of the year. The ‘safety net’ protects Australians from excessive pharmaceutical bills for the PBS listed prescriptions they need.

When you or your family reach the PBS threshold, you are generally entitled to discounted co-payments for the rest of the calendar year. If you have a relevant concessions card and reach your threshold, you might get listed medications free for the remainder of the year. If you have a partner, de facto partner and/or children under the age of 16 or under the age of 25 and a full-time student, you can all work together towards the same safety net threshold.

How do the thresholds work?

The current safety net threshold is $1,497.20 for general patients and $316.80 for concessional card holders and pensioners.

When this amount is reached, patients and/or their families can apply for a Safety Net Concession Card which entitles you to a reduced price for prescription medications for the remainder of the year. If you’ve reached your limit and have a relevant concessions card, you might get listed medications free for the remainder of the year.

Out of pocket costs to expect and extra charges

While the bulk of medication costs are covered, you may still need to make a PBS co-payment. You may be required to pay more than the co-payment if you choose a particular brand of medication or if the Government and supplier cannot agree on a price. You’ll also need to cover the difference if the prescribed drug exceeds the PBS drug price in the same therapeutic group. However, your doctor may request an exemption.

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How to use it

PBS medications are available to all Australians and concession cardholders who have a current Medicare card. To buy PBS medicines, you will need a doctor’s prescription.

How can you find out if the PBS covers the medicine you need?

The PBS subsidises the cost of several generic medications listed in the Schedule of Pharmaceutical Benefits for Approved Pharmacists and Medical Practitioners, also referred to as the PBS Schedule. The list is available on the PBS website.

Can I get help with prescription costs?

Through the PBS, the Australian Government subsidises medicines to make them more affordable. If you have a private prescription, meaning the medicine is not listed under the PBS, you’ll generally have to pay full price.

Does private health insurance cover medication?

Typically, private health insurance funds with Extras cover to allow you to claim for non-PBS medications. How much you are covered for depends on the type of policy you have.

How to claim pharmaceuticals from your health fund

Private health insurers offer several ways to make a claim. Generally, these are:

  • On-the-spot claims at electronic claiming terminals or HICAPS.
  • Online by logging in to the health fund’s membership portal and following the instructions.
  • On the health insurer’s app by submitting your receipts and documents via the app.
  • Manually by posting or dropping off a healthcare insurance claim form, your invoice and receipt.

Frequently asked questions and answers

  • Where does PBS get funding?

    The Australian Government funds the PBS. They are a part of the greater National Medicines Policy. The goal of both of these schemes is to offer reliable and affordable medicines to the general public. This ensures that health and economic goals are kept in balance.
  • What is a PBS prescription?

    This is the prescription you’ll receive from your care provider that allows you to access medication on the PBS list. Eligible prescribers such as doctors, dentists, nurses, midwives, and optometrists can write prescriptions for patients for medications listed on the PBS schedule.
  • How much do prescriptions cost in Australia?

    The Australian Government helps keep the costs of many medicines low through the PBS. Subsidised medication will cost you up to $41.30 per prescription, or $6.60 if you have a concession card.
  • Who decides which medicines are included on the PBS?

    Every medicine needs to pass an evaluation by the Therapeutic Goods Administration (TGA) for safety, quality and effectiveness before being sold in Australia. Once approved, the Pharmaceutical Benefits Advisory Committee (PBAC) do their own assessment regarding efficacy. The PBAC can then recommend that the medication be added to the PBS schedule.
  • How much is the PBS safety net?

    The current safety net threshold is $1,497.20 for general patients and $316.80 for concessional card holders and pensioners.
  • How much does medication cost without insurance?

    You will need to pay between $10 and $100 or more for non-PBS subsidised prescriptions. If you do not have private health insurance or the fund you have does not cover pharmaceuticals, you will need to foot the entire bill.

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  • Reduce out-of-pocket expenses
  • Keep your family healthy
  • Easy and convenient
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