{"id":"F2020L00059","name":"National Health (Commonwealth Price and Conditions for Commonwealth Payments for Supply of Pharmaceutical Benefits) Determination 2019","slug":"national-health-commonwealth-price-and-conditions-for-commonwealth-payments-for-supply-of-pharmaceut","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":100614,"registerId":"commonwealth-F2020L00059-current","compilationNumber":null,"startDate":"2026-04-02","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Part 1","sectionType":"part","heading":"Preliminary","content":"## Part 1—Preliminary","sortOrder":0},{"sectionNumber":"1","sectionType":"section","heading":"Name","content":"#### 1 Name\n\n  (1) This instrument is the National Health (Commonwealth Price and Conditions for Commonwealth Payments for Supply of Pharmaceutical Benefits) Determination 2019.\n  (2) This instrument may also be cited as PB 114 of 2019.","sortOrder":1},{"sectionNumber":"3","sectionType":"section","heading":"Authority","content":"#### 3 Authority\n\n  This instrument is made under subsection 98C(1) of the National Health Act 1953.","sortOrder":2},{"sectionNumber":"5","sectionType":"section","heading":"Simplified outline of this instrument","content":"#### 5 Simplified outline of this instrument\n\nThe Commonwealth price for pharmaceutical benefits supplied by an approved medical practitioner is worked out in the same way as the Commonwealth price for those benefits supplied by an approved pharmacist.\n\nThe Commonwealth will pay an approved medical practitioner or an approved pharmacist for supply of a pharmaceutical benefit only if certain conditions are met. They are as follows:\n\n(a) if a determination under subsection 85(6) of the Act specifies a brand of the benefit, payment will be made only for supply of that brand of the benefit;\n\n(b) if the benefit is specified in Schedule 4 to this instrument, payment will be made for supply of the benefit only if it is supplied in a complete pack.\n\nSchedules 1, 2, 3 and 5 list pharmaceutical benefits and ingredients of pharmaceutical benefits for which particular rules apply for working out the Commonwealth price (whether the benefits are supplied by an approved medical practitioner or an approved pharmacist).\n\nSchedule 4 lists pharmaceutical benefits that must be supplied in complete packs by an approved medical practitioner or an approved pharmacist for the practitioner or pharmacist to be paid by the Commonwealth for the supply.","sortOrder":3},{"sectionNumber":"6","sectionType":"section","heading":"Definitions","content":"#### 6 Definitions\n\n  In this instrument:\n\n> Act means the National Health Act 1953.\n\n> approved medical practitioner has the meaning given by subsection 84(1) of the Act.\n\n> approved pharmacist has the meaning given by subsection 84(1) of the Act.\n\n> brand has the meaning given by subsection 84(1) of the Act.\n\n> extemporaneously‑prepared pharmaceutical benefit has the meaning given by subsection 6(1) of the Commonwealth price (Pharmaceutical benefits supplied by approved pharmacists) Determination 2020 (PB 66 of 2020).\n\n> listed drug has the meaning given by subsection 84(1) of the Act.\n\n> pharmaceutical benefit has the meaning given by subsection 84(1) of the Act.\n\n> pharmaceutical item has the meaning given by section 84AB of the Act.","sortOrder":4},{"sectionNumber":"Part 2","sectionType":"part","heading":"Commonwealth price for pharmaceutical benefits supplied by approved medical practitioners","content":"## Part 2—Commonwealth price for pharmaceutical benefits supplied by approved medical practitioners","sortOrder":5},{"sectionNumber":"7","sectionType":"section","heading":"Commonwealth price for pharmaceutical benefits supplied by approved medical practitioners","content":"#### 7 Commonwealth price for pharmaceutical benefits supplied by approved medical practitioners\n\n  (1) For the purposes of paragraph 98C(1)(a) of the Act, this section provides for the manner of ascertaining the Commonwealth price for a quantity, or number of units, of a pharmaceutical benefit supplied by an approved medical practitioner, for the purposes of a payment to the practitioner in respect of the supply.\n  (2) The Commonwealth price is to be ascertained in the same manner as the Commonwealth price for the supply would have been worked out under the Commonwealth price (Pharmaceutical benefits supplied by approved pharmacists) Determination 2020 (PB 66 of 2020) if the supply had been made by an approved pharmacist.\n  (3) Schedules 1, 2, 3 and 5 identify pharmaceutical benefits and ingredients in relation to which particular rules for ascertaining the Commonwealth price apply.\n\n> Note: Those rules are in the Commonwealth price (Pharmaceutical benefits supplied by approved pharmacists) Determination 2020 (PB 66 of 2020), which is relevant because of subsection (2) of this section.","sortOrder":6},{"sectionNumber":"Part 3","sectionType":"part","heading":"Conditions on payments for pharmaceutical benefits supplied by approved pharmacists and approved medical practitioners","content":"## Part 3—Conditions on payments for pharmaceutical benefits supplied by approved pharmacists and approved medical practitioners","sortOrder":7},{"sectionNumber":"8","sectionType":"section","heading":"Scope of this Part","content":"#### 8 Scope of this Part\n\n  For the purposes of paragraph 98C(1)(b) of the Act, this Part sets out the conditions subject to which payments will be made by the Commonwealth in respect of the supply of pharmaceutical benefits by approved pharmacists and approved medical practitioners.","sortOrder":8},{"sectionNumber":"9","sectionType":"section","heading":"Condition on payment for supply of certain pharmaceutical items","content":"#### 9 Condition on payment for supply of certain pharmaceutical items\n\n  If a determination under subsection 85(6) of the Act is in force for a brand of a pharmaceutical item consisting of a drug or medicinal preparation, payments will be made by the Commonwealth in respect of the supply of the drug or preparation only if that brand is supplied.","sortOrder":9},{"sectionNumber":"10","sectionType":"section","heading":"Payment for supply of certain pharmaceutical benefits in complete packs","content":"#### 10 Payment for supply of certain pharmaceutical benefits in complete packs\n\n  Payments will be made by the Commonwealth in respect of the supply of a listed drug in a form described in columns 1 and 2 of an item of Schedule 4 only if the quantity supplied is the quantity contained in a unit of the size described in column 2 of the item (even if the prescription for the supply is for supply of a lesser quantity).","sortOrder":10}],"analysis":{"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"},"kimi_summary":{"content_quality":"ok","complexity_score":5,"scope_assessment":{"changed":false,"description":"The instrument appears consistent with its original purpose. It implements subsection 98C(1) of the National Health Act 1953, which specifically provides for Commonwealth price and conditions for pharmaceutical benefits. The scope remains tightly focused on pricing and payment conditions for PBS medicines supplied by authorised providers."},"complexity_factors":["Heavy reliance on external instruments — the core pricing mechanism is defined by reference to a separate 2020 determination (PB 66 of 2020), requiring readers to cross-reference another document","Multiple defined terms (7 definitions) that themselves refer to definitions in the parent National Health Act 1953, creating a chain of references","Conditional logic with nested exceptions in the standard formula preparations table — the 'unless' clauses create three layers of conditions (addition, omission, variation of dose, or combination)","Schedule-dependent operation — the instrument's practical effect depends on content in Schedules 1-5, which are not fully reproduced in the provided text","Dual-application structure — same rules apply to two different provider types (medical practitioners and pharmacists) but through different legal mechanisms (direct application vs. incorporation by reference)"],"plain_english_summary":"This law fixes how much the Commonwealth pays approved medical practitioners and pharmacists for PBS medicines, aligning the price paid to doctors with the pharmacist price calculation and applying special pricing for listed “standard formula” compounding recipes. \n\nIt also conditions payments on specified-brand supply and, for certain listed medicines, on supplying the complete pack, to preserve consistency and prevent overpayment."},"flash_summary":{"complexity_score":4,"scope_assessment":{"changed":false,"description":"This instrument is a technical, administrative determination that aligns pricing and sets payment conditions for supplies by approved medical practitioners with the existing pharmacist pricing framework. It does not expand the subject matter beyond its original functional purpose (prescribing Commonwealth pricing mechanics and conditions for payment). The instrument relies on, and enforces, external determinations (brand determinations under s85(6) and the pharmacist price determination), but it does not materially broaden the policy scope beyond those technical pricing and payment conditions."},"complexity_factors":["Short primary text but heavy cross-referencing to external instruments (Commonwealth price (Pharmaceutical benefits supplied by approved pharmacists) Determination 2020 (PB 66 of 2020)) — see section 7 and the note to section 7","Multiple schedules (Schedules 1–5), which contain item lists and special rules that must be read with the body of the instrument (section 5 and section 7)","Definitions in section 6 that tie terms to the National Health Act 1953 and to other instruments, requiring readers to consult those sources for authoritative meanings","Conditional rules that depend on separate determinations under subsection 85(6) of the Act (section 9) — i.e. payment conditions are triggered by external administrative acts","Complete-pack payment rule (section 10) creates an exception to normal prescription flexibility and requires matching between prescription quantity and pack sizes listed in Schedule 4","Schedule 1 contains a multi-row table of standard formula (extemporaneous) preparations with exclusion rules (addition/omission/combination) — creates line-item complexity","Relatively few standalone provisions in the instrument itself, but significant interpretive complexity because the operative pricing mechanics live in PB 66 of 2020"],"plain_english_summary":"**What this instrument does (mechanically)\n\n- Sets how the Commonwealth price (the amount the federal government will pay) is calculated when an approved medical practitioner supplies a Pharmaceutical Benefit (section 7).  It does this by saying the price is worked out in the same way as if an approved pharmacist had supplied it — i.e. it delegates the pricing mechanics to the Commonwealth price (Pharmaceutical benefits supplied by approved pharmacists) Determination 2020 (PB 66 of 2020) (section 7).\n\n- Imposes conditions that must be met before the Commonwealth will pay for supplies by approved pharmacists or approved medical practitioners (Part 3). Two key conditions are:\n  - If there is a separate determination under subsection 85(6) of the National Health Act 1953 that specifies a particular brand for a pharmaceutical item, the Commonwealth will pay only if that brand is supplied (section 9).\n  - For certain listed drugs (identified in Schedule 4), the Commonwealth will pay only if the practitioner or pharmacist supplies the complete pack size listed in Schedule 4 — even if the prescription requests a smaller quantity (section 10 and Schedule 4).\n\n- Identifies particular pharmaceutical benefits and ingredients for which special pricing rules apply in Schedules 1, 2, 3 and 5 (section 7 and the Simplified outline, section 5). Schedule 1 also lists standard formula (extemporaneous) preparations and sets the boundary for when an extemporaneously prepared item qualifies as a standard formula preparation.\n\n- Provides definitions and ties certain terms to the National Health Act 1953 and to the pharmacist pricing determination (section 6).\n\n\nWhy the instrument matters (stated purpose and practical effects)\n\n- Stated purpose: to prescribe the Commonwealth price and conditions for Commonwealth payments when approved medical practitioners (and approved pharmacists) supply Pharmaceutical Benefits.  The instrument's simplifed outline says it aligns the Commonwealth price for supplies by medical practitioners with the method used for pharmacists and sets conditions for when the Commonwealth will pay (section 5).\n\n- Practical effects and who is affected:\n  - Who pays: the Commonwealth (federal government) pays under the National Health Act 1953 (Part 3, esp. sections 8–10).\n  - Who is paid: approved medical practitioners and approved pharmacists (definitions in section 6, and conditions in Part 3).\n  - Who decides eligibility for payment: the instrument refers to other statutory determinations (notably determinations under subsection 85(6) of the Act and the pharmacist pricing determination PB 66 of 2020). Those determinations and the schedules in this instrument determine whether a supply qualifies for payment (sections 6, 7, 9, 10).\n  - Behaviour changes this creates: practitioners and pharmacists must check whether a brand has been mandated (and supply that brand to be paid) and must supply full pack sizes for certain listed drugs to receive Commonwealth payment. They must also apply the pricing method set out in PB 66 of 2020 when claiming the Commonwealth price for supplies by medical practitioners (section 7; sections 9–10; Schedules 1–5).\n\n\nTesting the stated purpose against likely costs, incentives and administrative effects\n\n- Delegation of pricing mechanics to the pharmacist determination (PB 66 of 2020) reduces duplication of pricing rules (section 7) but increases reliance on that external instrument. That means understanding the Commonwealth price in practice requires reading PB 66 of 2020 alongside this instrument (see note to section 7).\n\n- Brand-specific payment condition (section 9) creates a clear compliance rule: if the Minister/Secretary has specified a brand by a separate determination, only that brand will be paid for. Mechanically this channels payments to specified brands; the instrument itself does not set which brands, it enforces payment rules once brand determinations exist. The immediate effect is that suppliers must stock and supply the nominated brand to receive Commonwealth payment; manufacturers of the nominated brand receive concentrated benefit when a brand determination exists (section 9).\n\n- Complete-pack requirement for some listed drugs (section 10 and Schedule 4) means the Commonwealth will not pay for smaller quantities even if prescribed; suppliers therefore face an inventory and dispensing decision: either supply the full pack (and be paid) or supply a smaller quantity but not be paid by the Commonwealth (section 10). That shifts purchase/stocking incentives onto suppliers and may change out-of-pocket arrangements with patients.\n\n- Compliance and administrative burden: practitioners and pharmacists must track (a) whether a supply is listed in any of the Schedules, (b) whether a brand determination under s85(6) applies to that item, and (c) the pricing rules in PB 66 of 2020. This adds some record‑checking and systems work for dispensers and clinics (sections 5–7, 9–10).\n\n- Implementation risk: because the instrument cross-references external determinations and the Act, changes to PB 66 of 2020 or to statutory brand determinations will affect how this instrument operates. The instrument is short and technical but operationally depends on other instruments remaining accessible and consistent (section 7 and section 6 definitions).\n\n\nKey references in the instrument\n\n- Delegation of pricing method to the pharmacist price determination: section 7.\n- Conditions on payment for brand-specific items: section 9.\n- Conditions on payment only for complete packs: section 10 and Schedule 4.\n- Lists of items and special rules: Schedules 1, 2, 3 and 5 (section 7 and simplified outline, section 5).\n- Definitions linking terms to the National Health Act 1953 and PB 66 of 2020: section 6.\n\n\nBottom line (mechanical summary)\n\nThis is a technical instrument that (1) makes Commonwealth payments to approved medical practitioners subject to the same pricing rules used for approved pharmacists (by cross-reference to PB 66 of 2020), and (2) imposes two principal conditions for payment: compliance with any brand-specific determinations and supplying certain listed drugs only in the full pack sizes listed in Schedule 4. It primarily affects dispensing and billing behaviour by approved medical practitioners and pharmacists, and relies on cross-referenced determinations and schedules for the detailed pricing and item lists (sections 7–10 and Schedules 1–5)."}},"importantCases":[],"_links":{"self":"/api/acts/national-health-commonwealth-price-and-conditions-for-commonwealth-payments-for-supply-of-pharmaceut","history":"/api/acts/national-health-commonwealth-price-and-conditions-for-commonwealth-payments-for-supply-of-pharmaceut/history","analysis":"/api/acts/national-health-commonwealth-price-and-conditions-for-commonwealth-payments-for-supply-of-pharmaceut/analysis","conflicts":"/api/acts/national-health-commonwealth-price-and-conditions-for-commonwealth-payments-for-supply-of-pharmaceut/conflicts","importantCases":"/api/acts/national-health-commonwealth-price-and-conditions-for-commonwealth-payments-for-supply-of-pharmaceut/important-cases","documents":"/api/acts/national-health-commonwealth-price-and-conditions-for-commonwealth-payments-for-supply-of-pharmaceut/documents"}}