{"id":"F2017L01298","name":"National Health (Entitlement to Pharmaceutical Benefits—Special Evidentiary Categories) Determination 2017","slug":"f2017l01298","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":439354,"registerId":"F2017L01298-fast-fetch-1775955410329","compilationNumber":null,"startDate":"2026-04-12","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"section","heading":"National Health (Entitlement to Pharmaceutical Benefits—Special Evidentiary Categories) Determination 2017","content":"---\nmeta-content-style-type: text/css\nmeta-content-type: application/xhtml+xml; charset=utf-8\n---\n\n?xml version=\"1.0\" encoding=\"utf-8\" standalone=\"no\"?>\n\n![](image.001.jpeg)\n\n \n\n \n\nPB 83 of 2017\n\n \n\nNational Health (Entitlement to Pharmaceutical Benefits—Special Evidentiary Categories) Determination 2017\n\nI, Louise Clarke, as delegate of the Minister for Health, make the following determination.\n\nDated  27 September 2017\n\nLouise Clarke\n\nActing First Assistant Secretary\n\nTechnology Assessment and Access Division\n\nDepartment of Health\n\n \n\n \n\n \n\n \n\nContents\n\nPart 1—Preliminary\n\n1 Name\n\n2 Commencement\n\n3 Authority\n\n4 Schedules\n\n5 Definitions\n\n6 Purpose of this instrument\n\nPart 2—Classes of persons\n\n7 Determination of classes\n\nPart 3—Matters of which approved suppliers must be satisfied\n\n8 Eligible persons requiring drugs or medicinal preparations in an emergency\n\n9 Foreign persons covered by reciprocal health care agreements\n\n10 Persons without a medicare number who a PBS prescriber identifies as entitled to pharmaceutical benefits\n\n11 Persons without a medicare number who an approved supplier considers are entitled to pharmaceutical benefits\n\n12 Eligible persons requiring drugs or medicinal preparations as a matter of clinical urgency\n\n13 Persons for whom an inapplicable medicare number is shown on a seemingly valid medicare card or document\n\nPart 4—Procedure for allocation of special numbers\n\n14 Allocating special numbers\n\nSchedule 1—Repeals\n\nNational Health (Entitlement to Pharmaceutical Benefits — Special Evidentiary Categories) Determination 2001\n\n \n\nPart 1—Preliminary\n\n \n\n1  Name\n\n (1) This instrument is the National Health (Entitlement to Pharmaceutical Benefits—Special Evidentiary Categories) Determination 2017.\n\n (2) This instrument may also be cited as PB 83 of 2017.\n\n2  Commencement\n\n (1) Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.\n\n \n\n- Commencement information\n- Column 1 Column 2 Column 3\n- Provisions Commencement Date/Details\n- 1. The whole of this instrument 1 October 2017. 1 October 2017\n\n\nNote: This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.\n\n (2) Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.\n\n3  Authority\n\n  This instrument is made under subsection 86E(1) of the National Health Act 1953.\n\n4  Schedules\n\n  Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.\n\n5  Definitions\n\nNote: For the definition of eligible person, see subsection 4(1A) of the Act and subsection 3(1) of the Health Insurance Act 1973.\n\n  In this instrument:\n\nAct means the National Health Act 1953.\n\napproved supplier has the same meaning as in Part VII of the Act.\n\nmedicare card has the same meaning as in Part VII of the Act.\n\nmedicare number has the same meaning as in Part VII of the Act.\n\nPBS prescriber has the same meaning as in Part VII of the Act.\n\npharmaceutical benefit has the same meaning as in Part VII of the Act.\n\nreciprocal health care agreement means an agreement made under section 7 of the Health Insurance Act 1973.\n\nspecial number has the same meaning as in Part VII of the Act.\n\n6  Purpose of this instrument\n\n  This instrument:\n\n (a) determines the classes of persons in respect of whom an entitlement to pharmaceutical benefits can be evidenced otherwise than by provision of a medicare number; and\n\n (b) sets out the particular matters in respect of which an approved supplier must be satisfied before being satisfied that a person is included within a particular class identified in this instrument; and\n\n (c) sets out, for certain matters mentioned in paragraph (b), the procedure to be followed by the approved supplier in establishing the matters; and\n\n (d) includes a procedure for allocating a special number applicable to a person included within a class.\n\nPart 2—Classes of persons\n\n \n\n7  Determination of classes\n\n  Each of the following is a class of persons in respect of whom an entitlement to pharmaceutical benefits can be evidenced otherwise than by provision of a medicare number:\n\n (a) eligible persons requiring drugs or medicinal preparations in an emergency;\n\n (b) foreign persons covered by reciprocal health care agreements;\n\n (c) persons without a medicare number who a PBS prescriber identifies as entitled to pharmaceutical benefits;\n\n (d) persons without a medicare number who an approved supplier considers are entitled to pharmaceutical benefits;\n\n (e) eligible persons requiring drugs or medicinal preparations as a matter of clinical urgency;\n\n (f) persons for whom an inapplicable medicare number is shown on a seemingly valid medicare card or document.\n\nPart 3—Matters of which approved suppliers must be satisfied\n\n \n\n8  Eligible persons requiring drugs or medicinal preparations in an emergency\n\n  An approved supplier must be satisfied of the following matters before being satisfied that a person is in the class mentioned in paragraph 7(a):\n\n (a) there is no reason to believe that the person is not, or is not entitled to be treated as, an eligible person;\n\n (b) the person or another person is likely to suffer imminent death, serious ill health or serious injury (the emergency);\n\n (c) to prevent that emergency, the prescribed pharmaceutical benefit must be supplied:\n\n (i) immediately; or\n\n (ii) within a period that is too short to enable questions relating to eligibility or identity to be asked and answered, or for other action to be taken to establish the person’s eligibility or identity.\n\n9  Foreign persons covered by reciprocal health care agreements\n\n (1) An approved supplier must be satisfied of the following matters before being satisfied that a person is in the class mentioned in paragraph 7(b):\n\n (a) the person is covered by a passport issued by a country with which there is in force a reciprocal health care agreement;\n\n (b) the passport has not expired;\n\n (c) there is no reason to believe that the person has a medicare number applicable to the person.\n\n (2) To be satisfied of the matters mentioned in paragraphs (1)(a) and (b), the approved supplier must examine the passport covering the person.\n\n (3) To be satisfied of the matter mentioned in paragraph (1)(c), the approved supplier must have asked the person, or the person’s agent, whether there is a medicare number applicable to the person.\n\n10  Persons without a medicare number who a PBS prescriber identifies as entitled to pharmaceutical benefits\n\n  An approved supplier must be satisfied of the following matters before being satisfied that a person is in the class mentioned in paragraph 7(c):\n\n (a) the PBS prescriber has indicated on the prescription that they consider the person to be entitled to pharmaceutical benefits;\n\n (b) there is no reason to believe that the person is not, or is not entitled to be treated as, an eligible person;\n\n (c) there is no reason to believe that the person has a medicare card or document issued by the Chief Executive Medicare that shows a medicare number applicable to the person.\n\n11  Persons without a medicare number who an approved supplier considers are entitled to pharmaceutical benefits\n\n  An approved supplier must be satisfied of the following matters before being satisfied that a person is in the class mentioned in paragraph 7(d):\n\n (a) the person is an eligible person (but not a person treated as an eligible person under a reciprocal health agreement);\n\n (b) either:\n\n (i) there is no reason to believe that the person has a medicare card or document issued by the Chief Executive Medicare that shows a medicare number applicable to the person; or\n\n (ii) it is not reasonable to require the person to otherwise provide, or give the approved supplier permission to obtain, a medicare number applicable to the person.\n\n12  Eligible persons requiring drugs or medicinal preparations as a matter of clinical urgency\n\n  An approved supplier must be satisfied of the following matters before being satisfied that a person is in the class mentioned in paragraph 7(e):\n\n (a) there is no reason to believe that the person is not, or is not entitled to be treated as, an eligible person;\n\n (b) the immediate supply of the prescribed pharmaceutical benefit is clinically necessary:\n\n (i) to initiate urgent treatment; or\n\n (ii) to continue without interruption an existing regime of treatment.\n\n13  Persons for whom an inapplicable medicare number is shown on a seemingly valid medicare card or document\n\n (1) An approved supplier must be satisfied of the following matters before being satisfied that a person is in the class mentioned in paragraph 7(f):\n\n (a) there is no reason to believe that the person is not, or is not entitled to be treated as, an eligible person;\n\n (b) the approved supplier has made a previous claim for payment by the Commonwealth in relation to the supply of a pharmaceutical benefit to the person;\n\n (c) the previous claim included a number that appears to be a medicare number applicable to the person, as shown on a medicare card or document issued by the Chief Executive Medicare;\n\n (d) the previous claim was rejected because the number did not correspond with a medicare number that was held in the records of the Chief Executive Medicare as applicable to the person;\n\n (e) the approved supplier is unable to obtain another medicare number applicable to the person.\n\n (2) To be satisfied of the matter mentioned in paragraph (1)(c), the approved supplier must obtain a true and readable photocopy or photograph of the medicare card or document.\n\nPart 4—Procedure for allocation of special numbers\n\n \n\n14  Allocating special numbers\n\n (1) The special number allocated to a person must be the number specified in subsection (2) for the class of persons that the person is included in.\n\n (2) The special number for a class is as follows:\n\n (a) for eligible persons requiring drugs or medicinal preparations in an emergency (paragraph 7(a))—2543 77541 1 1;\n\n (b) for foreign persons covered by reciprocal health care agreements (paragraph 7(b))—2543 77596 1 1;\n\n (c) for persons without a medicare number who a PBS prescriber identifies as entitled to pharmaceutical benefits (paragraph 7(c))—2543 77666 1 1;\n\n (d) for persons without a medicare number who an approved supplier considers are entitled to pharmaceutical benefits (paragraph 7(d))—2543 77684 1 1;\n\n (e) for eligible persons requiring drugs or medicinal preparations as a matter of clinical urgency (paragraph 7(e))—2543 75299 1 1;\n\n (f) for persons for whom an inapplicable medicare number is shown on a seemingly valid medicare card or document (paragraph 7(f))—2543 77833 1 1.\n\nSchedule 1—Repeals\n\n \n\nNational Health (Entitlement to Pharmaceutical Benefits — Special Evidentiary Categories) Determination 2001\n\n1  The whole of the instrument\n\nRepeal the instrument.\n\n \n","sortOrder":0}],"analysis":{"flash_summary":{"complexity_score":4,"scope_assessment":{"changed":true,"description":"This instrument expressly repeals the National Health (Entitlement to Pharmaceutical Benefits — Special Evidentiary Categories) Determination 2001 (Schedule 1) and replaces it with the classes, evidentiary requirements and special-number allocations set out here (ss.4; Schedule 1). The text does not contain a direct comparison to the 2001 instrument, so whether the substantive policy scope differs cannot be determined from this instrument alone; legally, the scope is now as specified in this 2017 Determination."},"complexity_factors":["Multiple discrete classes (6) with different evidentiary rules (s.7) increasing conditional complexity.","Significant supplier discretion: approved supplier must be 'satisfied' on various matters (ss.8–13), requiring judgment about eligibility and identity.","Operational checks with documentary requirements (passport examination s.9(2); photocopy/photograph s.13(2)) create compliance steps.","Interaction with external records and actors: asking about Medicare numbers (s.9(3)), reliance on Chief Executive Medicare records (s.13(1)(d)), and PBS prescriber endorsements (s.10(a)).","Ambiguous standards like 'no reason to believe' and 'not reasonable to require' (ss.8(a), 11(b)(ii)) leave scope for interpretation and contestation.","Hard-coded numeric 'special numbers' for each class (s.14(2)) impose precise operational/IT requirements for suppliers and claim systems.","Cross-references to other Acts and defined terms (Act, Medicare definitions, reciprocal health care agreements) require reading across statutes (s.5)."],"plain_english_summary":"This instrument sets out six classes of people who may receive Pharmaceutical Benefits Scheme (PBS) medicines without providing a Medicare number and prescribes the checks an approved supplier must make before supplying and claiming payment. It also allocates specific “special numbers” to use when claiming for each class and repeals the earlier 2001 Determination, leaving the approved supplier with primary responsibility to decide eligibility in the moment (see ss.7–14)."},"kimi_summary":{"content_quality":"ok","complexity_score":3,"scope_assessment":{"changed":false,"description":"The legislation maintains its original narrow purpose: establishing exceptional circumstances for accessing pharmaceutical benefits without standard Medicare evidence. The 2017 version appears to be a straightforward re-enactment/replacement of the 2001 Determination with updated special numbers, without expansion into new policy areas or additional evidentiary categories."},"complexity_factors":["Short instrument: approximately 14 substantive sections plus preliminary matters","Minimal defined terms: only 7 definitions in section 5, with most terms incorporated by reference to the National Health Act 1953","Clear structure: four logical parts (Preliminary, Classes of persons, Matters for satisfaction, Procedure for special numbers)","Simple conditional logic: each category has 2-5 specific criteria that must be met, with no nested exceptions or cross-references between categories","No interlocking provisions: each of the six categories in Part 3 operates independently with self-contained requirements","Straightforward procedural requirements: section 14 simply maps each class to a fixed 11-digit special number","Single repeal schedule: straightforward repeal of the 2001 predecessor instrument"],"plain_english_summary":"This law lets approved suppliers dispense subsidised PBS medicines without a Medicare number in six special circumstances — using category-specific substitute codes — so patients don’t miss essential treatment during emergencies, reciprocity-covered visits, clinician- or pharmacist-identified eligibility, clinical urgency, or faulty cards.  \n\nIt affects pharmacists, PBS prescribers, patients in those situations, and the Department of Health by preserving access to medicines while enabling claims and payment tracking."},"flash_summary_failed":{"failed":true,"reason":"Unauthenticated. Configure AI_GATEWAY_API_KEY or use a provider module. Learn more: https://ai-sdk.dev/unauthenticated-ai-gateway","source":"analysis-cron"}},"importantCases":[],"_links":{"self":"/api/acts/f2017l01298","history":"/api/acts/f2017l01298/history","analysis":"/api/acts/f2017l01298/analysis","conflicts":"/api/acts/f2017l01298/conflicts","importantCases":"/api/acts/f2017l01298/important-cases","documents":"/api/acts/f2017l01298/documents"}}