{"id":"F2021L00235","name":"National Health (Paraplegic and Quadriplegic Program) Special Arrangement 2021","slug":"national-health-paraplegic-and-quadriplegic-program-special-arrangement-2021","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":101349,"registerId":"commonwealth-F2021L00235-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 Special Arrangement is the National Health (Paraplegic and Quadriplegic Program) Special Arrangement 2021.\n  (2) This Special Arrangement may also be cited as PB 31 of 2021.","sortOrder":1},{"sectionNumber":"3","sectionType":"section","heading":"Authority","content":"#### 3 Authority\n\n  This Special Arrangement is made under section 100 of the National Health Act 1953.","sortOrder":2},{"sectionNumber":"4","sectionType":"section","heading":"Definitions","content":"#### 4 Definitions\n\n  In this Special Arrangement:\n\n> ABN has the same meaning as in the A New Tax System (Australian Business Number) Act 1999.\n\n> Act means the National Health Act 1953.\n\n> authorised association means a paraplegic and quadriplegic association authorised to supply pharmaceutical benefits under this Special Arrangement by section 9.\n\n> eligible person means a person that is eligible to receive pharmaceutical benefits under section 10.\n\nNote: Terms used in this Special Arrangement have the same meaning as in the Act—see section 13 of the Legislation Act 2003. These terms include:\n\n approved ex‑manufacturer price\n\n brand\n\n claimed price\n\n listed drug\n\n pack quantity\n\n pharmaceutical benefit\n\n pharmaceutical item\n\n proportional ex‑manufacturer price\n\n responsible person.","sortOrder":3},{"sectionNumber":"5","sectionType":"section","heading":"Pharmaceutical benefits covered by this Special Arrangement","content":"#### 5 Pharmaceutical benefits covered by this Special Arrangement\n\n  (1) This Special Arrangement applies to each pharmaceutical benefit mentioned in Schedule 1.\n  (2) Each pharmaceutical benefit to which this Special Arrangement applies is a brand of a listed drug mentioned in Schedule 1:\n    (a) in the form mentioned in Schedule 1 for the listed drug; and\n    (b) with the manner of administration mentioned in Schedule 1 for the form of the listed drug.\n\n> Note: Each listed drug mentioned in Schedule 1 has been declared by the Minister under subsection 85(2) of the Act. The form, manner of administration and brand mentioned in Schedule 1 have been determined by the Minister under subsections 85(3), (5) and (6) of the Act respectively.","sortOrder":4},{"sectionNumber":"6","sectionType":"section","heading":"Application of Part VII of the Act","content":"#### 6 Application of Part VII of the Act\n\n  (1) Each pharmaceutical benefit supplied in accordance with this Special Arrangement is supplied under Part VII of the Act.\n  (2) A provision of Part VII of the Act, or of regulations or other instruments made for Part VII of the Act, applies subject to this Special Arrangement.\n\nNote: See subsection 100(3) of the Act.","sortOrder":5},{"sectionNumber":"7","sectionType":"section","heading":"Responsible person","content":"#### 7 Responsible person\n\n  (1) If a code is mentioned in the column in Schedule 1 headed ‘Responsible Person’ for a brand of a pharmaceutical item, the person mentioned in paragraph (2)(a) is the responsible person for the brand of the pharmaceutical item.\n  (2) For subsection (1):\n    (a) the person is the person mentioned in Schedule 2 for the code, with the ABN, if any, mentioned in Schedule 2 for the person; and\n    (b) the pharmaceutical item is the listed drug mentioned in Schedule 1:\n    (i) in the form mentioned in Schedule 1 for the listed drug; and\n    (ii) with the manner of administration mentioned in Schedule 1 for the form of the listed drug.\n\nNote: A person identified by a code in the column headed ‘Responsible Person’ in Schedule 1 has been determined by the Minister, under section 84AF of the Act, to be the responsible person for the brand of the pharmaceutical item.","sortOrder":6},{"sectionNumber":"8","sectionType":"section","heading":"No prescriber or prescription","content":"#### 8 No prescriber or prescription\n\n  (1) If a pharmaceutical benefit is supplied in accordance with this Special Arrangement, the following determinations do not apply to the supply:\n    (a) a determination made under section 88 of the Act about PBS prescribers for the pharmaceutical benefit;\n    (b) a determination made under paragraph 85(7)(b) of the Act about the circumstances in which a prescription for the pharmaceutical benefit may be written;\n    (c) a determination made under paragraph 85A(2)(a) of the Act about the maximum quantities or number of units of the pharmaceutical item in the pharmaceutical benefit that may, in 1 prescription, be directed to be supplied on any 1 occasion;\n    (d) a determination made under paragraph 85A(2)(b) of the Act about the maximum number of occasions on which the pharmaceutical benefit may be directed to be supplied in a prescription.","sortOrder":7},{"sectionNumber":"Part 2","sectionType":"part","heading":"Supply for the paraplegic and quadriplegic program","content":"## Part 2—Supply for the paraplegic and quadriplegic program","sortOrder":8},{"sectionNumber":"9","sectionType":"section","heading":"Paraplegic and quadriplegic associations","content":"#### 9 Paraplegic and quadriplegic associations\n\n  The following paraplegic and quadriplegic associations are authorised to supply pharmaceutical benefits under this Special Arrangement:\n    (a) The Paraplegic & Quadriplegic Association of NSW (ABN 42 000 355 948); and\n    (b) Independence Australia Group (ABN 80 973 805 243).","sortOrder":9},{"sectionNumber":"10","sectionType":"section","heading":"Eligible persons","content":"#### 10 Eligible persons\n\n  A person is eligible to receive a pharmaceutical benefit from an authorised association if the person:\n    (a) is an eligible person within the meaning of the Health Insurance Act 1973; and\n    (b) has paraplegia or quadriplegia; and\n    (c) is a member of the association.","sortOrder":10},{"sectionNumber":"11","sectionType":"section","heading":"Maximum amount","content":"#### 11 Maximum amount\n\n  (1) The maximum amount of the pharmaceutical item in a pharmaceutical benefit that may, during a month, be supplied by an authorised association to an eligible person is the amount mentioned in the column in Schedule 1 headed ‘Maximum Amount’ for the pharmaceutical benefit.\n  (2) For subsection (1):\n    (a) the pharmaceutical item is the listed drug mentioned in Schedule 1:\n    (i) in the form mentioned in Schedule 1 for the listed drug; and\n    (ii) with the manner of administration mentioned in Schedule 1 for the form of the listed drug; and\n    (b) the pharmaceutical benefit is the brand of the listed drug mentioned in Schedule 1:\n    (i) in the form mentioned in Schedule 1 for the listed drug; and\n    (ii) with the manner of administration mentioned in Schedule 1 for the form of the listed drug.","sortOrder":11},{"sectionNumber":"12","sectionType":"section","heading":"Supply","content":"#### 12 Supply\n\n  (1) An authorised association may supply a pharmaceutical benefit to an eligible person:\n    (a) on the person’s request; and\n    (b) despite section 89 of the Act, without a prescription written for the supply to the person.\n\nNote: Section 89 of the Act provides for pharmaceutical benefits to be supplied only on prescription.\n\n  (2) The association may supply the pharmaceutical benefit to the person by:\n    (a) making the pharmaceutical benefit available to be picked up by the person at the association’s premises; or\n    (b) sending the pharmaceutical benefit to the person.","sortOrder":12},{"sectionNumber":"13","sectionType":"section","heading":"Co‑payment etc. not to be made","content":"#### 13 Co‑payment etc. not to be made\n\n  An authorised association must not demand or receive a payment or other valuable consideration for the supply of a pharmaceutical benefit under this Special Arrangement, other than:\n    (a) a payment from the Commonwealth under section 14.\n    (b) a charge mentioned in section 15.","sortOrder":13},{"sectionNumber":"14","sectionType":"section","heading":"Payment from Commonwealth","content":"#### 14 Payment from Commonwealth\n\n  (1) An authorised association that supplies a pack quantity of a pharmaceutical benefit is entitled to be paid by the Commonwealth for the supply the amount worked out under subsection (2).\n  (2) For subsection (1), the amount is:\n    (a) if there is no claimed price for the pack quantity of the pharmaceutical benefit:\n    (i) the price to pharmacists for the pack quantity worked out under the determination under paragraph 98B(1)(a) of the Act; and\n    (ii) a handling fee of 2.75% of that amount; or\n    (b) if there is a claimed price for the pack quantity of the pharmaceutical benefit:\n    (i) the claimed price for the pack quantity plus a wholesale mark‑up calculated in accordance with subsection (3); and\n    (ii) a handling fee of 2.75% of that amount.\n  (3) For paragraph (2)(b), the wholesale mark‑up for the pack quantity of the pharmaceutical benefit is to be worked out using the methodology for calculating the wholesale mark‑up for ready‑prepared pharmaceutical benefits in the determination under paragraph 98B(1)(a) of the Act, subject to the following:\n    (a) for the purposes of identifying the appropriate wholesale mark‑up formula in Step 2 of the methodology, the ex‑manufacturer price for the relevant quantity is to be worked out proportionately from the approved ex‑manufacturer price or proportional ex‑manufacturer price for the pack quantity of the pharmaceutical benefit; and\n    (b) otherwise, the methodology is to be applied as if the claimed price for the pack quantity of the pharmaceutical benefit were the approved ex‑manufacturer price or proportional ex‑manufacturer price for the pack quantity.","sortOrder":14},{"sectionNumber":"15","sectionType":"section","heading":"Charge for delivery","content":"#### 15 Charge for delivery\n\n  If an authorised association supplies a pharmaceutical benefit by sending it to a person the association may charge the person an amount that is equal to the cost of sending the pharmaceutical benefit to the person.","sortOrder":15},{"sectionNumber":"16","sectionType":"section","heading":"Claims for payment","content":"#### 16 Claims for payment\n\n  (1) An authorised association that wants to receive payment for the supply of a pharmaceutical benefit under this Special Arrangement must make a claim for payment to the Chief Executive Medicare.\n  (2) The Chief Executive Medicare must determine the amount payable for a claim made under this Part and make any payment relating to the claim.\n  (3) Despite section 99AAA of the Act, the association must submit its claims for the supplies it makes during a month on a form approved in writing by the Chief Executive Medicare for this section.\n\nNote: Section 99AAA of the Act provides for rules to be made by the Minister about procedures for claims for payment.","sortOrder":16},{"sectionNumber":"17","sectionType":"section","heading":"Stock of pharmaceutical benefits etc.","content":"#### 17 Stock of pharmaceutical benefits etc.\n\n  An authorised association may:\n    (a) order a pharmaceutical benefit from:\n    (i) the responsible person for the brand of the pharmaceutical item in the pharmaceutical benefit; or\n    (ii) a wholesaler for the pharmaceutical benefit; and\n    (b) keep in stock at its premises an adequate supply of pharmaceutical benefits for supply to its members under this Special Arrangement.","sortOrder":17},{"sectionNumber":"18","sectionType":"section","heading":"Internal review of decisions","content":"#### 18 Internal review of decisions\n\n  Application for review\n  (1) A person who is affected by a decision of the Chief Executive Medicare under this instrument may apply to the Secretary for review of the decision.\n  (2) An application for review must:\n    (a) be in writing; and\n    (b) be made within:\n    (i) 28 days after the day the decision first came to the notice of the applicant; or\n    (ii) if the Secretary allows a longer period (whether before or after the end of the 28‑day period referred to in subparagraph (i))—that longer period.\n  Review of decision\n  (3) On receiving an application, the Secretary must:\n    (a) review the decision; and\n    (b) affirm, vary or set aside the decision; and\n    (c) if the Secretary sets aside the decision—make a new decision in substitution for the decision set aside.\n  (4) The decision (the decision on review) of the Secretary takes effect:\n    (a) on the day specified in the decision on review; or\n    (b) if a day is not specified—on the day the decision on review was made.\n  Notice of decision\n  (5) After the Secretary makes a decision under this section, the Secretary must give the applicant a written notice stating the following:\n    (a) the terms of the decision;\n    (b) the reasons for the decision.","sortOrder":18},{"sectionNumber":"19","sectionType":"section","heading":"Application of this Special Arrangement","content":"#### 19 Application of this Special Arrangement\n\n  This Special Arrangement applies to a supply of a pharmaceutical benefit that is made the day after registration.","sortOrder":19}],"analysis":{"flash_summary_failed":{"failed":true,"reason":"A positive credit balance is required for all requests, including BYOK, so fallback providers remain available. Add credits at https://vercel.com/d?to=%2F%5Bteam%5D%2F%7E%2Fai%3Fmodal%3Dtop-up to continue.","source":"analysis-cron"},"kimi_summary":{"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"The legislation appears tightly scoped to its original purpose. It establishes a discrete special arrangement for two named organisations to supply specific pharmaceutical benefits to members with paraplegia or quadriplegia. There is no evidence of scope creep; the arrangement is limited, specific, and directly implements the enabling provision (section 100 of the National Health Act 1953) without expanding into adjacent policy areas."},"complexity_factors":["Multiple cross-references to the National Health Act 1953 (sections 84AF, 85, 88, 89, 98B, 99AAA, 100) and the Health Insurance Act 1973","Reliance on undefined Schedules 1 and 2 for substantive operational details (which drugs, which responsible persons, maximum amounts)","Nested conditional logic in payment calculations (section 14) with alternative pathways depending on existence of 'claimed price'","Incorporation by reference of external determinations and methodologies (wholesale mark-up calculations)","13 defined terms in section 4, plus implicit definitions via the Legislation Act 2003","Specific ABN identification requirements for authorised associations"],"plain_english_summary":"This creates a special scheme letting two disability organisations (Paraplegic & Quadriplegic Association of NSW and Independence Australia Group) supply specified subsidised PBS medicines and continence products directly to eligible Medicare members with paraplegia or quadriplegia, without a doctor’s prescription. Members receive supplies by pickup or delivery at no cost (only postage if chosen); the organisations buy stock and claim government reimbursement plus a small handling fee. It reduces administrative barriers and improves ongoing access to essential supplies."},"flash_summary":{"complexity_score":3,"scope_assessment":{"changed":false,"description":"The instrument is narrowly self‑contained: it applies only to the pharmaceutical benefits listed in Schedule 1, authorises two specified associations to supply them to eligible paraplegic and quadriplegic members, sets quantity limits, payment rules and procedural requirements. The text shows no indication it expands or contracts the population, products or payment mechanisms beyond those specified in this Arrangement."},"complexity_factors":["Narrow, specialised scope limited to medicines listed in Schedule 1 reduces substantive legal complexity (s 5).","Cross‑references to multiple provisions of the National Health Act 1953 and its determinations (Part VII, ss 85, 98B) require administrators to apply external pricing formulas rather than self-contained rates (ss 6, 5, 14(2)–(3)).","Payment calculation includes a handling fee and a wholesale mark‑up methodology that adapts the Act’s ready‑prepared formula using proportional ex‑manufacturer prices — introduces technical pricing steps (s 14(2)–(3)).","Operational rules waive normal prescription and prescriber determinations, creating atypical supply mechanics that must be interpreted alongside existing prescription law (s 8, s 12).","Administrative requirements for claims and Chief Executive Medicare determinations impose procedural compliance obligations (s 16).","Limited number of authorised suppliers and eligibility tied to membership and Health Insurance Act status concentrates operational responsibility and discretion in named associations (ss 9–10).","Permitted postage charges and prohibition on co‑payments except Commonwealth payments create clear but narrow financial interactions to monitor (ss 13, 15).","Includes an internal review pathway for decisions of Chief Executive Medicare by the Secretary, adding an accountable administrative remedy but requiring timeliness and written reasons (s 18)."],"plain_english_summary":"This Special Arrangement authorises two named paraplegic and quadriplegic associations to supply specific PBS-listed medicines without individual prescriptions, sets monthly quantity limits, and prescribes Commonwealth payment rules (including a 2.75% handling fee and wholesale mark‑up methodology) and claim procedures. It affects eligible paraplegic and quadriplegic members, the authorised associations (who may order, stock and post medicines), and Medicare administration; the Commonwealth pays for supplies, associations cannot charge co‑payments except postage, and associations must submit monthly claims and have access to an internal review process (ss 9–16, 18)."}},"importantCases":[],"_links":{"self":"/api/acts/national-health-paraplegic-and-quadriplegic-program-special-arrangement-2021","history":"/api/acts/national-health-paraplegic-and-quadriplegic-program-special-arrangement-2021/history","analysis":"/api/acts/national-health-paraplegic-and-quadriplegic-program-special-arrangement-2021/analysis","conflicts":"/api/acts/national-health-paraplegic-and-quadriplegic-program-special-arrangement-2021/conflicts","importantCases":"/api/acts/national-health-paraplegic-and-quadriplegic-program-special-arrangement-2021/important-cases","documents":"/api/acts/national-health-paraplegic-and-quadriplegic-program-special-arrangement-2021/documents"}}