INFORMATION ON CLAIMING

At the end of each month, an online claim must be completed by the health service dispensing and claiming reimbursement for Highly Specialised Drugs. The online application is accessed by a user name and password. To access your user name and password, or if you have any problems with the online claiming application, please contact Michael Furey on (03) 9096 2506.

HSD Claim Online Application

Patient Co-payment: As a condition of funding, the Commonwealth requires that all patients pay a financial contribution for each supply of medication. The amount payable is comparable to the Pharmaceutical Benefits Scheme, either the general patient amount or the concessional amount as set in the fees manual.
The co-payment should be charged per medication per one month supply, regardless of the number of strengths required to make up that supply.

The Commonwealth assumes that each patient receives one month's supply at a time, therefore each patient is assumed to receive 12 separate occasions of dispensing annually. A formula is applied that is based on the percentage of general, concessional and free patients, from data collected by the Pharmaceutical Benefits Scheme system as to the proportion of each category of patient, and establishes an average patient co-payment.

In the case of public hospitals the co-payment will be deducted as part of the calculations for total revenue. Accordingly, payment will be made on gross figures.

Dispensing Information: The Commonwealth only funds agreed strengths for each drug. For example, there might be a range of strengths for a drug but only some of these strengths or formulations will be funded under the Program. It is important that hospitals use only agreed strengths and should clearly indicate the quantity of each funded strength used in a given claim period. It is incumbent upon pharmacy staff to keep up to date with information on drugs provided by circulars. Please note that the claim works on a principle of lowest common denominator and are marked for item numbers not pack numbers.

Gross Expenditure: This figure is calculated by multiplying the total number of items per strength and then summing the total cost per strength to give a total gross expenditure.

Certification: The Certification by Prescribing Doctor form (PDF File 18KB) must be completed by a person in a position to comment on whether the drug(s) was dispensed according to the relevant Pharmaceutical Benefits Advisory Committee clinical indications and that the Highly Specialised Drugs Program criteria have been met. The certification must also clearly indicate the person's name and position, the date of certification, the hospital and, where appropriate, hospital campus.

Arrangements for the supply of ABATACEPT, ADALIMUMAB, AMBRISENTAN, AZACITIDINE, BOSENTAN, EPOPROSTENOL, ETANERCEPT, ILOPROST, INFLIXIMAB, LENALIDOMIDE, OMALIZUMAB, RITUXIMAB, ROMIPLOSTIM, SILDENAFIL and TOCILIZUMAB: All Commonwealth funded supply of these drugs require individual patient authority approval from Medicare Australia prior to dispensing. The prescription requirements and the arrangements for dispensing and claiming are available at:

http://www.medicareaustralia.gov.au/provider/pbs/highly-specialised-drugs/complex-authority-drugs.jsp

Victorian public hospitals MUST claim these drugs directly via Medicare Australia.

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