Questions and answers - $5 pharmaceutical co-payments

Information for pharmacists, prescribers and the public about co-payment eligibility.

The pharmaceutical co-payment is usually $5 per new prescription item. There are no prescription co-payment charges for subsidised medicine for children under 13 years of age.

Families and individuals who are prescribed more than 20 items in a year will qualify for a prescription subsidy. Go to Prescription subsidy scheme to find out more.

The definition of family for eligibility for the scheme is:

  • a married (or de facto) couple, with one or more dependent children or
  • a married (or de facto) couple, with no dependent children or
  • one person with or without children.

Pharmaceutical co-payment questions and answers

  1. What should a pharmacist do when presented with an un-coded non-hospital prescription?
  2. If the pharmacist believes a prescription is coded incorrectly can the pharmacist alter the coding to A4 without confirming with the prescriber?
  3. Should prescriptions for an enrolled patient who is accessing services from a non-PHO prescriber be treated as A3, or does the funding follow the patient, regardless of prescriber?
  4. Patients who are eligible for subsidised medicines, but receive a prescription from a PHO general practice where they are not enrolled may be automatically coded A3 by Practice Management Systems software. Can the pharmacist alter the code on these prescriptions so the patient is charged the correct co-payment?
  5. Can a pharmacist assume that all scripts for New Zealand citizens and Permanent Residents are eligible for the $5 co-payment if the prescription is issued by a doctor from a DHB hospital, but the prescription is not coded?
  6. Should providers manually alter a computer-generated prescription if is incorrectly coded?
  7. Does the $5 co-payment apply to GP specialist clinics?
  8. What about the $2 co-payment previously paid by some Prescription Subsidy Card holders?
  9. What is the position for Accident and Medical Centres (ie, after hours) if they are not enrolling patients?
  10. Are casuals eligible for $5 co-payments?
  11. Does a patient have to be enrolled with a PHO to be eligible if they get a prescription from a source that is not their regular doctor? Is it dependent on whether a person is enrolled with a PHO or just whether the doctor who wrote the prescription is an approved prescriber?
  12. If the prescription does not have a National Health Index (NHI) number on it does it still attract a $5 co-payment?
  13. Is it the intention that Australian and UK tourists are now eligible for $5 co-payments?
  14. Is an ACC-accredited Accident and Medical centre offering after-hours services able to access reduced co-payments for their patients?

1. What should a pharmacist do when presented with an un-coded non-hospital prescription? For example, a prescription from a PHO after-hours prescriber or midwife with a DHB access agreement, etc

If the prescription is not coded the pharmacist needs to confirm that the:

  • patient is eligible for publicly funded pharmaceuticals
  • prescriber is approved for co-payments.

When the pharmacist has established whether the patient is eligible and whether the prescriber is an approved prescriber the pharmacist can decide what the correct code is for co-payment purposes. However, the pharmacist must have information which they can point to and which they believe is factual that indicates that the prescription is issued by an approved prescriber for an eligible person. Examples include:

  • a DHB list of approved providers
  • that the prescription is written on a public hospital prescription pad
  • advice from the Ministry that the prescriber is approved (such as midwives and family planning clinics).

The alteration to the coding on the prescription should be done in a manner that is identifiable and auditable, as required in the Pharmacy Procedures Manual v 7.2 at clause 6.13 for annotations.

Guidance on determining eligibility for publicly funded pharmaceuticals

The pharmacist can determine a patient’s eligibility for publicly funded pharmaceuticals by:

  • checking with the prescriber or
  • verifying eligibility directly with the patient.

The pharmacist is entitled to rely on the prescriber’s information about the patient’s eligibility.

A patient may directly provide proof of eligibility by proving that they are a New Zealand citizen or having the correct permits in their passport. For guides on how to establish eligibility, see the Resources for service providers pages of the Eligibility for publicly funded health services section.

Guidance on determining whether the prescriber is an approved provider

Without exception all prescriptions for fully subsidised medicines for patients eligible for publicly funded services that are obtained from a public hospital prescriber, a midwife and/or a Family Planning Clinic prescriber are approved for $5 co-payments.

In the case of other prescribers/providers, the pharmacist can either check with the prescriber or rely on the DHB's information about approved and non-approved providers/prescribers.

The following providers are approved if they meet the specified criteria.

  • After-hours providers with an access or service agreement with a DHB or a PHO are approved. The DHB can provide pharmacists with a list of approved after-hours providers.
  • Youth health clinics are approved if the clinic has a DHB contract for services.
  • Dentists are approved if the prescription relates to a service being provided under a DHB contract.
  • Private specialists (eg, ophthalmology, orthopaedics) are approved if the prescription relates to a patient receiving a publicly funded service contracted by the DHB.
  • During normal business hours (ie, not after hours) general practitioners where the person is not enrolled (ie, ‘casual’ visits) are approved if the person is an eligible person and the general practice is part of a PHO.
  • Hospices are approved if they have a contract with a DHB.

Any provider/prescriber not specifically listed by the DHB as an approved provider/prescriber should be treated as not approved.

The following providers/prescribers are not approved

The following list specifies the circumstances under which a prescriber/provider is not approved for $5 co-payments on publicly funded pharmaceuticals. DHBs may also provide a list of the general practitioners in their district who are not approved.

  • General practitioners who are not part of a PHO are not approved unless they have other DHB service agreements for publicly funded services.
  • Private specialists are not approved if the prescription does not relate to a patient receiving a publicly funded service contracted by the DHB and is issued in the course of their private practice and relates to a private patient receiving a privately funded service.
  • Providers/prescribers providing a service that is privately funded and do not have a contract with either the Ministry, a DHB or a PHO are not approved.

When the pharmacist has established whether the person is eligible and whether the prescriber can prescribe publicly funded pharmaceuticals, the pharmacist can decide what the correct code is for co-payment purposes. If a prescription for an eligible person is not coded for the correct co-payment, the pharmacist can complete the missing factual information. This should be done in a manner that is identifiable and auditable, as required in the Pharmacy Procedures Manual v 7.2 at clause 6.13 for annotations.

2. If the pharmacist believes a prescription is coded incorrectly (eg, coded A31 for a patient who is known to the pharmacy to be enrolled in a local PHO but who is accessing services from an alternative provider – after hours, midwife, dentist, etc.) – can the pharmacist alter the coding to A42 without confirming with the prescriber?

Where a patient is eligible for publicly funded medicines and the prescriber is approved for $5 co-payments on subsidised medicines and the pharmacist has information that indicates the prescription is coded incorrectly, the pharmacist may alter the code. However, the pharmacist must have information which they can point to and which they believe is factual. Examples include:

  • a DHB list of approved providers
  • that the prescription is written on a public hospital prescription pad
  • advice from the Ministry that the prescriber is approved (such as midwives and family planning).

The alteration to the coding on the prescription should be done in a manner that is identifiable and auditable, as required in the Pharmacy Procedures Manual v 7.2 at clause 6.13 for annotations.

3. Should prescriptions for an enrolled patient who is accessing services from a non-PHO prescriber be treated as A3, or does the funding follow the patient, regardless of prescriber? For example, in the case of prescriptions for boarders at a high school where the school uses a non-PHO prescriber to provide any prescriptions required for boarders

The funding does not automatically follow the patient regardless of prescriber. The answer to question 1 above provides guidance on determining if a prescriber is an approved prescriber.

General practitioners who are not part of a PHO and are operating on a Section 88 notice alone are not approved prescribers for $5 co-payments on subsidised medicines. In cases such as these, the non-PHO prescriber could join a PHO and thereby become an approved prescribe or the school and/or patient can change to an approved prescriber.

4. Patients who are eligible for subsidised medicines, but receive a prescription from a PHO general practice where they are not enrolled may be automatically coded A3 by Practice Management Systems (PMS) software. Can the pharmacist alter the code on these prescriptions so the patient is charged the correct co-payment?

The $5 co-payment subsidy applies to ‘approved’ prescribers. If the patient is eligible for subsidised medicines and the prescriber is ‘approved’ to issue the $5 co-payment code on prescriptions then the pharmacist can alter the prescription code to A4. However, the pharmacist must have information which they can point to and which they believe is factual. Examples include:

  • a DHB list of approved providers
  • that the prescription is written on a public hospital prescription pad
  • advice from the Ministry that the prescriber is approved (such as midwives and family planning).

The alteration to the coding on the prescription should be done in a manner that is identifiable and auditable, as required in the Pharmacy Procedures Manual v 7.2 at clause 6.13 for annotations.

5. Can a pharmacist assume that all scripts for New Zealand citizens and Permanent Residents are eligible for the $5 co-payment if the prescription is issued by a doctor from a DHB hospital, but the prescription is not coded?

If the prescription is identifiable as a DHB public hospital prescription and the patient is eligible for publicly funded medicines, the pharmacist can alter (or insert) the code on the prescription. The alteration to the coding on the prescription should be done in a manner that is identifiable and auditable, as required in the Pharmacy Procedures Manual v 7.2 at clause 6.13 for annotations.

6. Should providers manually alter a computer-generated prescription if is incorrectly coded?

If a computer-generated prescription has incorrect information (including the co-payment code) the prescriber should manually correct it and initial the change.

7. Does the $5 co-payment apply to GP specialist clinics? Examples are: men’s health clinics, sports medicine clinics, travel medicine clinics and alternative therapy clinics

If these specialist clinics are not provided under a DHB or a PHO agreement then they would not be an approved provider. Check the list of DHB-approved prescribers.

8. What about the $2 co-payment previously paid by some Prescription Subsidy Card holders?

From 1 July 2015, the $2.00 co-payment has been removed. Once a patient (or a member of their family) belongs to the prescription subsidy scheme, the patient will be exempt from paying a co-payment. The patient is exempt, irrespective of whether they hold a Community Services Card and/or a High User Health Card.

9. What is the position for Accident and Medical Centres (ie, after hours) if they are not enrolling patients?

The patient has to be eligible for publicly funded services, but does not have to be enrolled in a PHO if the prescriber is approved. Whether the Accident and Medical Centre is approved to prescribe publicly funded medicine will depend on whether they have a DHB or a PHO service agreement. Check with DHB for a list of approved after hours providers.

10. Are casuals3 eligible for $5 co-payments?

The patient has to be eligible for publicly funded services, but does not have to be enrolled in a PHO if the prescriber is approved. If the casual visit is to a general practice that is part of a PHO, or to any other approved prescriber then they should be charged a $5 co-payment on subsidised medicines.

11. Does a patient have to be enrolled with a PHO to be eligible if they get a prescription from a source that is not their regular doctor? Is it dependent on whether a person is enrolled with a PHO or just whether the doctor who wrote the prescription is an approved prescriber?

The patient has to be eligible for publicly funded services, and the prescriber must be approved to prescribe publicly funded medicines. The patient does not have to be enrolled in a PHO.

12. If the prescription does not have a National Health Index (NHI) number on it does it still attract a $5 co-payment?

There has been no change to the NHI requirements for prescriptions. However, an NHI number is not an indicator of the eligibility of the patient. If the NHI is not provided on a prescription the patient may be eligible for $5 co-payments if the patient is eligible for publicly funded services and the provider is an approved provider.

13. Is it the intention that Australian and UK tourists are now eligible for $5 co-payments?

If the medical condition meets the necessary requirements and the patient meets the necessary eligibility conditions then they will be eligible for a pharmaceutical subsidy. Although the tourist cannot join a PHO, if the prescriber is an approved provider/prescriber the $5 co-payment will apply.

An Australian citizen or Australian permanent resident on a temporary visit to New Zealand, who requires medical treatment that is immediately and clinically necessary for the diagnosis, alleviation or care of that condition, will be entitled to subsidised pharmaceuticals in relation to that condition only.

A UK citizen, temporarily in New Zealand, who requires prompt medical treatment for a condition arising after they arrived in New Zealand (or became acutely exacerbated after arrival), will be entitled to subsidised pharmaceuticals in relation to that condition only.

14. Is an ACC-accredited Accident and Medical centre offering after-hours services able to access reduced co-payments for their patients?

ACC prescriptions are funded by ACC, but ACC advise that all ACC-related prescriptions should be coded A4 for a $5 co-payment. For medical-related prescriptions, as opposed to accident-related ones, the after-hours provider would have to have a DHB or a PHO contract. The DHB can provide a list of approved after-hours providers.


Footnotes:

  1. An A3 code indicates the prescription for an adult aged 18 years or over and that the level of the co-payment should be up to a maximum of $15.
  2. An A4 code indicates that the prescription is for an adult aged 18 or over and that the level of the co-payment should be up to a maximum of $5.
  3. Casual patients are patients that the practice has not enrolled.
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