How PBS Safety Net bureaucracy is stopping patients saving money on medicines

Nearly 500,000 Australians could be missing out on hundreds of dollars in savings at the pharmacy each year because of poor understanding and uptake of the country's "clunky" pharmaceutical safety net scheme.

While both sides of parliament have promised to cut the maximum price for scheduled scripts from $31.60 down to $25, attention is also turning to the Pharmaceutical Benefits Scheme (PBS) Safety Net, which operates alongside reduced script prices.

Last year more than 2.3 million Australians enrolled in the PBS Safety Net scheme, which gives patients cheaper subsidised medicines once they spend a certain amount.

But a further 495,865 people who qualified for the safety net missed out on savings because they didn't make use of the scheme, according to new data from the federal Department of Health and Ageing.

Under the scheme, script prices for general patients drop from $31.60 to $7.70 once they spend more than $1,694 a year on prescription medicines.

Scripts for concession card holders, such as pensioners and low-income earners, go from $7.70 to free once they spend over $277 annually.

The figures were evidence of serious problems with the administration of the program and showed too many patients were missing out, health groups said.

One key problem was poor awareness of the scheme, said patient advocate Elizabeth Deveny from the Consumers Health Forum of Australia.

"People often tell us that they've not heard of this safety net, and so they've never used it and never got the benefit," she said.

Patients must shop at same pharmacy

Under the current system, patients must shop at the same pharmacy if they want to try to qualify for the safety net.

That is because patient spending data isn't centralised and individual pharmacy computer systems calculate when customers reach the thresholds.

It's a problem for patients like mother-of-two Kirsten Eustace, who has an immune condition and often needs prescription medicines, so tries to shop around for the best price.

"You have to go to the same pharmacy regularly to be able to qualify. It becomes very monopolistic and anti-competitive," she said.

"It's 2025. We should be able to have all of our purchases automatically put onto our records."

If people want to shop around, they need to keep a handwritten log using a prescription record form downloaded from the Services Australia website.

Failing that, they can ask their pharmacist to phone other pharmacies and reconcile their spending.

Ms Deveny described it as a "clunky" process.

"People shouldn't have to jump through hoops to get the medicine they need in an affordable way," she said.

The situation is made even more difficult for families because family members on a single Medicare card are not automatically linked in the pharmacies' systems, and patients must notify the pharmacist.

But wait, it gets harder

Complicating matters even further is that once people reach the safety net, the pharmacy computer systems issue a card with a code that patients use for the remainder of the year to get discounted scripts.

However, the pharmacist must print out the associated paperwork and send it by post to Services Australia to register the patients. Services Australia then must process it within 12 weeks, or the code will stop working.

Pharmacy Guild president Trent Twomey said a backlog happened last year and many customers suddenly stopped qualifying for discounted scripts.

"Last year the average processing time for a safety net card was nearing six months," he said.

"We were seeing families and households who had spent a fortune on medication that year finally reach their safety net and then have it switched off again."

Ms Deveny said fixing the system in a cost-of-living crisis was "a no-brainer".

The government has agreed under its latest long-term agreement with pharmacies to automate the system within five years — but Mr Twomey said they want to see those plans fast-tracked "so we can deliver the much-needed cost of living relief to Australians now".

A Health and Ageing Department spokesperson said there was a lot involved in automating the safety net.

"Costs … are expected to involve legislation, ICT systems, processes, communications and education materials and other flow-on impacts."

Elderly patients also miss out

More than 2.2 million people using the safety net are concession card holders and some of these are elderly patients who encounter specific problems with the program.

The safety net is calculated by adding up all the spending by everyone on a single Medicare card, whether that's an individual, a couple or a family.

Elderly couples who share the same Medicare card will often spend enough on medications to qualify for the safety net.

But pharmacists say a problem arises when one spouse moves into aged care while the other stays in the community, because the couple's spending on medications across the nursing home and community pharmacies won't be added together.

"What we see a lot of times is medication bills jump when one of the partners get put into care," Mr Twomey said

Early 60-day scripts impact the safety net

Another problem, according to pharmacists, is the scheme's interaction with 60-day scripts.

Under the current rules if a patient needs to fill a repeat 60-day script within 50 days of their last script it either won't count towards their safety net, or, if they've already qualified, they won't get their discount.

"So you can be missing out every second month to your safety net," Mr Twomey said.

A health department spokesperson said in these instances GPs were supposed to get a special prescribing authorisation, which would prevent this happening.

General safety net not dropped to match price drop

Pharmacists argued the general safety net threshold needed to be lowered, following cuts in the maximum PBS script price to $31.90.

With patients paying less for each script, fewer non-concession card holders were now reaching the threshold. Between 2019 and 2024, 25,000 fewer general patients qualified for the scheme following the price drops.

Ms Eustace said her family often came close to the threshold but never reached it.

"I think that it is probably far too complex for what it needs to be," she said.

The number of concession patients in the scheme has grown by 1 million because they fared much better under the changes — they only need to reach a safety net of $277, which is about 36 scripts a year.

A spokesperson for the Department of Health and Ageing said the safety net was designed to help people or families who had a significant number of scripts each year.

"The government has a responsibility to ensure that the PBS is managed in a fiscally responsible and sustainable way," they said.