Logo: Department of HealthLogo: Pharmaceutical Benefits SchemeScenarios
PBS XML Schema Version 3.1.7

This document details how to use the PBS XML to extract information for various scenarios.

Item Delist: Supply-Only

A change to a medicine where an item code is delisted and a new item code is added and/or an existing item code remains. Scripts written for the delisted item code prior to the date of delisting are valid for supply after the date of delisting.

This situation is handled using the supply-only effectivity element. The item and product listings to be delisted is instead changed to supply-only effectivity. If the product listings to be delisted, and now supply-only, are substitutable with the product listings under the new item code then the brand substitution group remains effective.

Figure 1. Supply-only Items

Supply-only Items

For an example in test data see items 9661L, 9678J and 10064Q.

Delisting of Equivalent Item

Where items that are considered equivalent for the purpose of substitution are added or delisted from the Schedule. As long as the 'pharmaceutical benefit' (i.e. either of the equivalent items) is listed at the date of prescribing and the date of dispensing the script is valid for payment.

This situation is handled using the supply-only effectivity element. The product listings that are substitutable (i.e. TPPs listed under PBS items that are 'equivalent') are members of the same brand substitution group. The brand substitution group remains effective while any of its product listing members are effective.

Figure 2. Equivalent Items

Equivalent Items

Complex Authority Required

Certain PBS Items (prescribing rules) are classified as "Complex Authority Required" (CAR). These are known as 'CAR Items'. There are two different meanings to the phrase "CAR":

  • The legal definition of a CAR drug, or

  • The administration by Department of Human Services to:

    • Authorise prescribing of the medicine

    • Dispense the medicine

PBS Items in the Public Hospital HSD program (HB) that are marked as 'Administrative CAR' may be dispensed by a Community Pharmacy. Such items may have either a Streamlined or Authority Required restriction level (benefit type).

Legal CAR Items

A "Complex Authority Required drug" is defined in the legislative instrument National Health (Highly specialised drugs program) Special Arrangement 2010 (PB 116 of 2010), see Part 1, Division 1, Section 4 Definitions.

Every prescribing rule is a member of one of the http://pbs.gov.au/complex-authority-required groups. There are two groups of this type: http://pbs.gov.au/complex-authority-required/is-complex and http://pbs.gov.au/complex-authority-required/not-complex. A prescribing rule must be a member of exactly one of these groups; it cannot be a member of both.

A Legal CAR Item is identified in the PBS XML by being a member of the group http://pbs.gov.au/complex-authority-required/is-complex. For example,

Example 1. Legal CAR Item

<prescribing-rule>
  ...
  <member-of-list>
    ...
    <member-of rdf:resource='http://pbs.gov.au/complex-authority-required/is-complex'>
      <code rdf:resource="http://pbs.gov.au/code/group">is-complex</code>
      <effective>
        <date>2019-02-01</date>
      </effective>
    </member-of>
  </member-of-list>
</prescribing-rule>

A prescribing rule that is not a Legal CAR Item is identified in the PBS XML by being a member of the group http://pbs.gov.au/complex-authority-required/not-complex. For example,

Example 2. Prescribing Rule that is not legal CAR

<prescribing-rule>
  ...
  <member-of-list>
    ...
    <member-of rdf:resource='http://pbs.gov.au/complex-authority-required/not-complex'>
      <code rdf:resource="http://pbs.gov.au/code/group">not-complex</code>
      <effective>
        <date>2017-08-01</date>
      </effective>
    </member-of>
  </member-of-list>
</prescribing-rule>

Administrative CAR Items

Some PBS Items have more complex administrative requirements for the Department of Human Services. Such items are indicated by the presence of an administrative-advice element that is associated with the PBS Ontology concept http://pbs.gov.au/DHS/authority/complex. Such an element is known as a 'CAR Note'.

Example 3. CAR Note

<administrative-advice xml:id="a25639" rdf:resource="http://pbs.gov.au/DHS/authority/complex">
  <code rdf:resource="http://pbs.gov.au/code/prescribing-text">11165</code>
  <dbk:note>
    <dbk:para>For details on the appropriate minimum exercise program that will be accepted for the purposes of administering this restriction, please refer to the Department of Human Services website at www.humanservices.gov.au</dbk:para>
  </dbk:note>
  <effective>
    <date>2017-09-01</date>
   </effective>
</administrative-advice>

References to a CAR Note may be made directly from a prescribing rule, or from a restriction that is attached to a prescribing rule. As long as there is at least one CAR Note attached to the prescribing rule, then the entire prescribing rule is considered to be an Administrative CAR Item.

CAR Note on a Prescribing Rule

A CAR Note may be directly referenced from a prescribing rule. In this case, there is an administrative-advice-reference element that links to a CAR Note in the prescribing rule's prescribing-text-references-list element.

Example 4. CAR Note Reference, Prescribing Rule

<prescribing-rule>
  <prescribing-text-references-list>
    <administrative-advice-reference xlink:href="#a25639">
      <code rdf:resource="http://pbs.gov.au/code/prescribing-text">11165</code>
      <effective>
        <date>2017-09-01</date>
      </effective>
    </administrative-advice-reference>
  </prescribing-text-references-list>
  ...
</prescribing-rule>

CAR Note on a Restriction

Alternatively, a CAR Note may be referenced from a restriction that is attached to a prescribing rule. In this case, there is an administrative-advice-reference element that links to a CAR Note in the content of the restriction. The restriction, in turn, is referenced from a restriction-references-list element in the prescribing rule.

Example 5. CAR Note Reference, Restriction

<prescribing-rule>
  <benefit-types-list>
    <benefit-type rdf:resource="http://pbs.gov.au/benefit-type/authority-required">
      <restriction-references-list>
        <restriction-reference xlink:href="#a13912">
          <code rdf:resource="http://pbs.gov.au/code/restriction">5965</code>
          <effective>
            <date>2017-09-01</date>
          </effective>
        </restriction-reference>
      </restriction-references-list>
      <effective>
        <date>2017-09-01</date>
      </effective>
    </benefit-type>
  </benefit-types-list>
  ...
</prescribing-rule>

<restriction xml:id="a13912">
  <code rdf:resource="http://pbs.gov.au/code/restriction">5965</code>
  <code rdf:resource="http://pbs.gov.au/code/treatment-of">6189</code>
  <assessment rdf:resource="http://pbs.gov.au/assessment/full">
    <code rdf:resource="http://pbs.gov.au/assessment">full</code>
    <effective>
      <date>2017-09-01</date>
    </effective>
  </assessment>
  <indication-reference xlink:href="#a35361">
    <code rdf:resource="http://pbs.gov.au/code/prescribing-text">10646</code>
    <effective>
      <date>2017-09-01</date>
    </effective>
  </indication-reference>
  <administrative-advice-reference xlink:href="#a25639">
    <code rdf:resource="http://pbs.gov.au/code/prescribing-text">11165</code>
    <effective>
      <date>2017-09-01</date>
    </effective>
  </administrative-advice-reference>
  <effective>
    <date>2017-09-01</date>
  </effective>
</restriction>


Increases

Increases to Maximum Quantity and/or Number of Repeats.

Every prescribing rule specifies the amount by which the Maximum Quantity (Maximum Amount for infusibles) and/or Number of Repeats may be increased. The increase amount is represented by the increase element. Each increase element describes whether the increase is permitted for Maximum Quantity or Number of Repeats, the Prescriber Types that the increase may be prescribed by, whether authority approval is required to prescribe the increase and the manner in which the approval may be sought, and finally any restrictions that may apply to the prescribing of the increase.

Figure 3. Restriction/Increase Data Model

Restriction/Increase Data Model

Increase Type and Value

Which value is permitted to be increased is given by the rdf:resource attribute of the increase. The following URIs may be specified:

http://pbs.gov.au/increase/maximum-prescribable

The value is the increase permitted to the maximum quantity (ready-prepared) or maximum amount (infusible).

http://pbs.gov.au/increase/number-repeats

The value is the increase permitted to the number of repeats.

The increase amount is specified by the value element.

If no increase is permitted then the value element will have the value 0.

Authority

Each increase element contains a single benefit-type element. This element serves the same purpose as for a prescribing rule. The rdf:resource attribute specifies whether authority approval is required for the increase and if so then the assessment that is performed to approve the authority application.

Example 6. Increase Authority

<increase rdf:resource="http://pbs.gov.au/increase/maximum-prescribable">
  <value>2</value>
  <benefit-type rdf:resource="http://pbs.gov.au/benefit-type/authority-required">
  ...
  </benefit-type>
</increase>

If no increase is permitted then the rdf:resource attribute will refer to the concept http://pbs.gov.au/benefit-type/none.

Prescriber Type

The benefit-type element also contains member-of elements that give the Prescriber Types for the increase.

Example 7. Increase Authority

<increase rdf:resource="http://pbs.gov.au/increase/maximum-prescribable">
  <value>2</value>
  <benefit-type rdf:resource="http://pbs.gov.au/benefit-type/authority-required">
    <member-of-list>
      <member-of rdf:resource="http://pbs.gov.au/prescriber/medical">
        <code>medical</code>
      </member-of>
      <member-of rdf:resource="http://pbs.gov.au/prescriber/nurse">
        <code>nurse</code>
      </member-of>
    </member-of-list>
  </benefit-type>
</increase>

Increase Restriction

If the authority requirement for the increase is authority-required then zero or more restrictions will be associated with the increase. Unlike a prescribing rule, the increase may omit references to restrictions, in which case the same restrictions apply to the increase as are specified for the prescribing rule. Where the increase does specify one or more restrictions the benefit-type element will contain one or more restriction-reference elements.

Example 8. Increase Restriction

<increase rdf:resource="http://pbs.gov.au/increase/maximum-prescribable">
  <value>2</value>
  <benefit-type rdf:resource="http://pbs.gov.au/benefit-type/authority-required">
    <member-of-list>
      <member-of rdf:resource="http://pbs.gov.au/prescriber/medical">
        <code>medical</code>
      </member-of>
      <member-of rdf:resource="http://pbs.gov.au/prescriber/nurse">
        <code>nurse</code>
      </member-of>
    </member-of-list>
    <restriction-references-list>
      <restriction-reference xlink:href="#d4639247">
        <effective>
        <date>2015-11-01</date>
        </effective>
      </restriction-reference>
    </restriction-references-list>
  </benefit-type>
</increase>

Stock Shortages

A stock shortage of an essential medicine where a new item code is listed and scripts written for the existing listing, that is out of stock, are valid for supply using the new item code. The unavailable item code remains listed.

In this situation the existing item code remains effective and a brand substitution group is created (if one does not already exist) that includes the new TPP (brand).

Drug Concept Code Change

All drug concepts have a SNOMED code. However, the code will be issued by either ADHA, as part of the AMT, or by the Department of Health. The AMT code for a drug concept is used where it is available, but sometimes this is not possible and a Health-issued code is used instead.

When a Health-issued code is used for a drug concept, at such time as an AMT code becomes available then Health will switch to using that code. It is also possible for a drug concept to switch from an AMT code to a Health-issued code.

This situation is handled using the history mechanism of the PBS XML Schema. In the case of a drug concept changing from a Health-issued code to an AMT code, the concept's code element will change it's rdf:resource attribute value from http://snomed.info/sct/911000144106 to http://snomed.info/sct/900062011000036108 and its content will change to the new value. The code element will also have a previous attribute added and it's value will correspond to the xml:id attribute of a previous element in the previous-list. The corresponding previous element will contain the image of the code element as it appeared in the previous month's Schedule.

For examples in test data see drug concepts indicated by XML comments.

Multiple Benefit Types

In some circumstances there can be different benefit types applying to different prescriber types within the same prescribing rule (i.e. under a single PBS Item Code).

This situation is handled by specifying two (or more) benefit-type elements in the prescribing rule's benefit-types-list element. Each benefit-type is a member of the group representing the prescriber type.

For an example in test data see item 1001Q.

Multiple Preferred Terms

In some circumstances there can be different preferred terms (names or descriptions) for an object. For example, a drug concept may have be described using one term for clinical purposes and another term for legal purposes.

This situation is handled by the object having two (or more) preferred-term elements. Each preferred-term may have a rdf:resource attribute to specify its meaning or use.

For an example in test data see the drug concept Bevacizumab.

Add a Restriction to a Prescribing Rule

A restriction may be added to a prescribing rule.

In this situation the restriction is actually added as a restriction-reference element to a benefit-type within the prescribing-rule. The effective date of the newly added restriction-reference element is the date of the publication.

There are two sub-scenarios: either the restriction is pre-existing or the restriction is new. For the former, there is no change to the pre-existing restriction. For the latter, the new restriction is also added to the PBS XML document and the effective date of the restriction is the date of the publication.

For an example in test data see the prescribing rule 1759N in the 1st January 2016 Schedule. This example adds three new restrictions to the prescribing rule, each of which is not pre-existing.

Remove a Restriction from a Prescribing Rule

A restriction may be removed from a prescribing rule.

In this situation the restriction-reference element is removed from the benefit-type element within the prescribing-rule. The restriction-reference element is replaced by a moved element. The effective date of the moved element is the date of the publication. The restriction-reference element now appears in a previous element in the previous-list section of the PBS XML document. The effective date of the old restriction-reference element is its original effective date and it will now have a non-effective date that is the date of the publication. The moved element and the previous element containing the old restriction reference both have a xlink:href attribute that link to each other.

NB. The history of restrictions for prescribing rules is retained over a twelve month period, so moved elements with older effective dates may also be included in the same restriction-references-list element.

There are two sub-scenarios: either the restriction itself is also removed or the restriction is still in active use by another prescribing rule. For the latter, there is no change to the restriction. For the former, the restriction is also replaced by a moved element and the old restriction will appear in a previous element.

For an example in test data see the prescribing rule 1759N in the 1st January 2016 Schedule. This example removes three restrictions from the prescribing rule.

Restriction Editorial Change

A restriction may be changed in a manner that is not significant, i.e. the intent or meaning of the restriction is unchanged. This is referred to as an editorial change. Examples of this type of change include correction of typographical or spelling errors. Changes of this nature do not cause the restriction's code to be changed.

In this situation the indication, treatment-phase, criteria or parameter element that changed is removed and a new, replacement element is added. Elements that are removed are replaced by a moved element and the element appears in the previous-list section of the XML document. Elements that are added have the effective date of the publication.

For an example in test data see the parameter 18169 in the 1st January 2016 Schedule.

Restriction Code Change

If a restriction changes its restriction code then it is considered to be a new restriction. In this case the old restriction is deleted and the new restriction is added.

If a restriction changes its treatment-of code, then its restriction code will also change; see above.

Streamlined Authority Code History

When a prescription for a streamlined authority item is to be dispensed then the script must have a valid Streamlined Authority Code (SAC). Values for SACs are taken from the treatment-of code for restrictions attached to the PBS Item. The SAC appearing on the script must have been valid at the time that the prescription was written, which may be up to 12 months prior to it being dispensed. However, the item's restrictions may have changed between the time that the prescription was written and the item dispensed.

This situation is handled by using the moved elements in the restriction-references-list element of the benefit-type for the prescribing rule. A Streamlined Authority Code is the treatment-of code given to a restriction for a prescribing rule that has a streamlined benefit type. These restrictions appear in the benefit type as a restriction-reference element. Whenever a restriction-reference element is removed, it is replaced by a moved element and the restriction-reference element then appears in the previous-list section of the PBS XML. The effective date of the moved element is the date that the restriction was removed. The PBS XML populates non-effective restriction-reference elements for a 12 month period prior to the effective date of the Schedule.

NB. the code included in the restriction-reference element is the restriction code, not the treatment-of code.

For an example in test data see item 10002K.

Brand Substitution

Every product-listing element is a member of a brand substitution group. Brand substitution groups belong to the concept type http://pbs.gov.au/brand-substitution/. The group contains those product listings that may be substituted for each other. The substitutable product listing gives the TPP and prescribing rule that may be substituted.

If a product listing is the only member of a brand substitution group then there are no other products that may be substituted.

Specialist Approval Only

An item must only be approved for an approved prescriber with a certain speciality code.

This scenario makes use of PBS terminology concepts in the rdf:RDF section of the PBS XML. In the PBS terminology, types of prescribers are represented at two levels: a broad categorisation of prescriber types and a more detailed list of specialists. The appropriate specialist concept is then linked to a prescriber-type restriction parameter.

Figure 4. Specialist Restriction Parameter

Specialist Restriction Parameter

Prescriber types are identified as being types of the http://pbs.gov.au/prescriber concept. These are the broad categories of prescriber types, such as Medical Practitioner (http://pbs.gov.au/prescriber/medical), Nurse Practitioner (http://pbs.gov.au/prescriber/nurse), Dental Practitioner (http://pbs.gov.au/prescriber/dental), and so on.

Specialist concepts are also identified as being types of the http://pbs.gov.au/prescriber concept. However, they are related to the broader concept using the skos:narrower and skos:broader relationships. These relationships may be used to represent a hierarchy of specialists.

Example 9. Specialist Terminology Concepts

<p:prescriber rdf:about="http://pbs.gov.au/prescriber/medical">
    <db:title>Medical Practitioner</db:title>
    <p:code>M</p:code>
    <skos:narrower rdf:resource="http://pbs.gov.au/prescriber/medical/rheumatologist"/>
  </p:prescriber>
  <p:prescriber rdf:about="http://pbs.gov.au/prescriber/medical/rheumatologist">
    <db:title>Rheumatologist</db:title>
    <db:para>A Rheumatologist is a medical specialist.</db:para>
    <skos:broader rdf:resource="http://pbs.gov.au/prescriber/medical"/>
    <skos:narrower rdf:resource="http://pbs.gov.au/prescriber/medical/rheumatologist/paediatric"/>
  </p:prescriber>
  <p:prescriber rdf:about="http://pbs.gov.au/prescriber/medical/rheumatologist/paediatric">
    <db:title>Paediatric Rheumatologist</db:title>
    <db:para>A specialist Rheumatologist.</db:para>
    <skos:broader rdf:resource="http://pbs.gov.au/prescriber/medical/rheumatologist"/>
  </p:prescriber>

For examples in test data see items 10001J, 3430M, 3431N and 6367D.

Sole PBS Subsidy

PBS Items that may only be approved providing other PBS Items are not approved in the patient's history.

Reciprocal Health Care

[Need further explanation of scenario]

RHCA

[Need further explanation of scenario]

Age Limitations

Age limitations for certain PBS Items and/or restrictions.

This scenario makes use of PBS terminology concepts in the rdf:RDF section of the PBS XML. In the PBS terminology, the age of a patient is represented by the http://pbs.gov.au/parameter/age concept. Specialisations of this concept represent variations and constraints on the age of the patient. The appropriate age related concept is then linked to an age-type restriction parameter.

Example 10. Age Limiting Terminology Concepts

  <p:parameter rdf:about="http://pbs.gov.au/parameter/age">
    <db:title>Age</db:title>
    <db:para>Patient's age.</db:para>
    <skos:broader rdf:resource="http://pbs.gov.au/criteria/population"/>
  </p:parameter>
  <p:parameter rdf:about="http://pbs.gov.au/parameter/age/min70">
    <db:title>Age 70 or older</db:title>
    <db:para>Patient must be aged 70 years or older</db:para>
    <skos:broader rdf:resource="http://pbs.gov.au/parameter/age"/>
    <xs:minInclusive>70</xs:minInclusive>
  </p:parameter>

For examples in test data see items 8481J, 9288W.

Gender Limitations

Gender limitations for certain PBS Items and/or restrictions.

This scenario makes use of PBS terminology concepts in the rdf:RDF section of the PBS XML. In the PBS terminology, the gender of a patient is represented by the http://pbs.gov.au/parameter/sex concept. Specialisations of this concept represent variations and constraints on the gender of the patient. The appropriate gender related concept is then linked to a sex-type restriction parameter.

Example 11. Gender Limiting Terminology Concepts

  <p:parameter rdf:about="http://pbs.gov.au/parameter/sex">
    <db:title>Sex</db:title>
    <db:para>Patient gender.</db:para>
    <skos:broader rdf:resource="http://pbs.gov.au/criteria/population"/>
  </p:parameter>
  <p:parameter rdf:about="http://pbs.gov.au/parameter/sex/male">
    <db:title>Male</db:title>
    <db:para>Patient must be male</db:para>
    <skos:broader rdf:resource="http://pbs.gov.au/parameter/sex"/>
    <owl:sameAs rdf:resource="http://snomed.info/sct/248153007"/>
  </p:parameter>

For examples in test data see items 10205D, 2114G.

Initial vs Continuing Therapy

Initial vs continuing therapy.

[Check that this is being handled by authority-required/streamlined listings]

Interchangeability

[Need further explanation of scenario]

Short-term Limitations

Short-term limitations.

Once in a Lifetime Drugs

Once in a lifetime drugs.

This scenario makes use of PBS terminology concepts in the rdf:RDF section of the PBS XML. In the PBS terminology, the treatment of a patient is represented by the http://pbs.gov.au/parameter/treatment/lifetime concept. Specialisations of this concept represent variations on the treatment the patient may receive in their lifetime. The appropriate specialist concept is then linked to a treatment-parameter-type restriction parameter.

Example 12. Lifetime Treatment Terminology Concepts

  <p:parameter rdf:about="http://pbs.gov.au/parameter/treatment/lifetime">
    <db:title>Treatment in a Lifetime</db:title>
    <db:para>Limitation on PBS-subsidised treatment of a patient in their lifetime</db:para>
    <skos:broader rdf:resource="http://pbs.gov.au/parameter/treatment"/>
    <skos:narrower rdf:resource="http://pbs.gov.au/parameter/treatment/lifetime1"/>
  </p:parameter>
  <p:parameter rdf:about="http://pbs.gov.au/parameter/treatment/lifetime1">
    <db:title>Once in a Lifetime Therapy</db:title>
    <db:para>A patient may only qualify for PBS-subsidised treatment under this restriction once in a lifetime.</db:para>
    <skos:broader rdf:resource="http://pbs.gov.au/parameter/treatment/lifetime"/>
    <xs:maxInclusive>1</xs:maxInclusive>
  </p:parameter>

For examples in test data see items 9411H, 10193L.