{"id":"F2022L01295","name":"National Health (Price and Special Patient Contribution) Determination 2022","slug":"national-health-price-and-special-patient-contribution-determination-2022","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":102703,"registerId":"commonwealth-F2022L01295-current","compilationNumber":null,"startDate":"2026-04-03","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"section","heading":"Name","content":"#### 1 Name\n\n  (1) This instrument is the National Health (Price and Special Patient Contribution) Determination 2022\n  (2) This instrument may also be cited as PB 98 of 2022.","sortOrder":0},{"sectionNumber":"3","sectionType":"section","heading":"Authority","content":"#### 3 Authority\n\n  This instrument is made under section 85B of the National Health Act 1953.","sortOrder":1},{"sectionNumber":"5","sectionType":"section","heading":"Definitions","content":"#### 5 Definitions\n\n  (1) In this instrument:\n\n> Act means the National Health Act 1953.\n\n> base‑priced drug in relation to a brand of a pharmaceutical item mentioned in Schedule 2 (the relevant brand), means all brands of pharmaceutical items that have:\n\n    (a) the same drug as the relevant brand; or\n    (b) a drug in the same therapeutic group as that drug;\n  and for which no price is determined under section 85B of the Act.\n\n> pack quantity has the same meaning as in subsection 84(1) of the Act.\n\n> Note: The Minister may determine one or more pack quantities for a brand of a pharmaceutical item under subsection 84AK(2) of the Act. The quantities determined are the quantities in a manufacturer’s PBS packs.\n\n> pricing quantity has the same meaning as in subsection 84(1) of the Act.\n\n> Note: Subsection 84AK(1) of the Act provides that the pricing quantity of a brand of a pharmaceutical item is the lowest of any pack quantity of any brand of the pharmaceutical item.\n\n> special patient contribution has the same meaning as in subsection 84(1) of the Act.","sortOrder":2},{"sectionNumber":"6","sectionType":"section","heading":"Determined price","content":"#### 6 Determined price\n\n  For the purposes of subsection 85B(2) of the Act, the amount that is, for the purposes of Part VII of the Act, taken to be the appropriate maximum price for the pricing quantity of a brand of a pharmaceutical item mentioned in Schedule 1 to this instrument, is the price for the brand mentioned in the column headed “Determined price” for the pricing quantity mentioned in the column headed “Pricing quantity/pack quantity”.","sortOrder":3},{"sectionNumber":"7","sectionType":"section","heading":"Claimed price","content":"#### 7 Claimed price\n\n  For the purposes of subsection 85B(3) of the Act, the amount that is, for the purposes of Part VII of the Act, taken to be the price claimed by the responsible person for a pack quantity of a brand of a pharmaceutical item mentioned in Schedule 1 to this instrument, is the price for the brand mentioned in the column headed “Claimed price” for the pack quantity mentioned in the column headed “Pricing quantity/pack quantity”.","sortOrder":4},{"sectionNumber":"8","sectionType":"section","heading":"Commonwealth payment of special patient contribution","content":"#### 8 Commonwealth payment of special patient contribution\n\n  (1) For the purposes of subsection 85B(4) of the Act, the circumstances in which the Commonwealth is to pay the special patient contribution for a brand of a pharmaceutical item are:\n    (a) the brand of pharmaceutical item is mentioned in Schedule 2 to this instrument; and\n    (b) the brand has been prescribed in a circumstance mentioned for the brand in Schedule 2 to this instrument; and\n    (c) either:\n    (i) writing the prescription has been authorised in accordance with section 19 of the National Health (Listing of Pharmaceutical Benefits) Instrument 2024; or\n    (ii) if the circumstances are not ones in which writing the prescription requires authorisation—the prescription satisfies the requirements of subsection (2).\n  (2) A prescription satisfies the requirements of this subsection if:\n    (a) the prescription or details of the prescription are submitted to the Chief Executive Medicare; and\n    (b) the Chief Executive Medicare authorises the prescription for the purposes of payment of the special patient contribution and allots a number to the prescription; and\n    (c) the allotted number is written on the prescription.\n  (3) For the purposes of this section, the pharmaceutical item is the listed drug mentioned in Schedule 2:\n    (a) in the form mentioned in Schedule 2 for the listed drug; and\n    (b) with the manner of administration mentioned in Schedule 2 for the form of the listed drug.","sortOrder":5}],"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":"This Determination appears consistent with its original purpose under section 85B of the National Health Act 1953, which has long empowered the Minister to determine pharmaceutical prices and special patient contribution arrangements. The instrument follows the established pattern of annual or periodic price determinations without apparent scope creep."},"complexity_factors":["Multiple cross-references to the National Health Act 1953 (sections 84, 84AK, 85B) and the National Health (Listing of Pharmaceutical Benefits) Instrument 2024","Technical pharmaceutical terminology requiring external knowledge: 'therapeutic group', 'pricing quantity', 'pack quantity', 'responsible person', 'listed drug'","Nested conditional logic in section 8 with three cumulative requirements (Schedule 2 listing + specific circumstance + authorisation alternative)","Dual pathway authorisation system in section 8(1)(c) with fallback requirements in subsection (2)","Dependent on external Schedules (1 and 2) not provided in the extract, which contain the actual price data and brand listings","5 defined terms in the interpretation section, but several rely on meanings imported from the parent Act"],"plain_english_summary":"This Determination fixes the maximum amounts the Australian Government will pay for certain PBS-listed medicines, records suppliers’ claimed pack prices, and specifies when the Commonwealth — via authorisation or Medicare approval — will cover special patient contributions for some high-cost drugs. It affects patients, prescribers, pharmacists, pharmaceutical suppliers and Medicare, and matters because it caps government reimbursement and determines whether patients face extra out‑of‑pocket costs."},"flash_summary":{"complexity_score":4,"scope_assessment":{"changed":false,"description":"This Determination does not alter which medicines are on the PBS; instead it fixes prices and the conditions under which the Commonwealth pays a special patient contribution for specified brands. It therefore changes reimbursement mechanics and administrative procedures (see sections 6–8 and Schedules 1–2) rather than the statutory scope of benefits."},"complexity_factors":["Direct cross‑references to the National Health Act, especially s85B, require understanding of external statutory provisions (see Authority, section 3).","Price mechanics are split between 'determined price' and 'claimed price' tied to distinct schedule entries, creating parallel pricing rules to reconcile (sections 6–7).","Definitions rely on other statutory concepts—'pack quantity' and 'pricing quantity'—and Ministerial determinations under s84AK, adding conditional delegation and variable units for pricing (Definitions, section 5).","The ‘base‑priced drug’ concept groups brands by drug or therapeutic group and depends on whether any price is otherwise determined under s85B, producing potential scope ambiguity (Definitions, section 5).","Payment of the special patient contribution requires procedural steps: prescription submission, Chief Executive Medicare authorisation and an allotted number to be recorded—introducing an administrative compliance burden (section 8(2)).","Dependence on another legislative instrument for authorisation rules (National Health (Listing of Pharmaceutical Benefits) Instrument 2024) links application and interpretation to an external instrument (section 8(1)(c)(i)).","Operational discretion lies with administrative officers (Chief Executive Medicare) and, indirectly, the Minister (pack quantities), concentrating implementation choices in executive decision‑makers (Definitions and section 8)."],"plain_english_summary":"This instrument sets the official prices and payment rules used under the National Health Act for specific PBS medicines. It fixes the ‘determined price’ (the maximum price taken for a pricing quantity) and the ‘claimed price’ for pack quantities for brands listed in Schedule 1, and specifies when the Commonwealth will pay a special patient contribution for brands listed in Schedule 2. It therefore changes reimbursement and administrative steps for manufacturers, pharmacies and patients; Commonwealth payment requires prescription authorisation or Chief Executive Medicare approval (see section 8)."}},"importantCases":[],"_links":{"self":"/api/acts/national-health-price-and-special-patient-contribution-determination-2022","history":"/api/acts/national-health-price-and-special-patient-contribution-determination-2022/history","analysis":"/api/acts/national-health-price-and-special-patient-contribution-determination-2022/analysis","conflicts":"/api/acts/national-health-price-and-special-patient-contribution-determination-2022/conflicts","importantCases":"/api/acts/national-health-price-and-special-patient-contribution-determination-2022/important-cases","documents":"/api/acts/national-health-price-and-special-patient-contribution-determination-2022/documents"}}