Not Approved Provider ($15 Co-pay) Pricing

Scripts from unapproved providers (specialists, for example) are coded as 3 when the patient does not have a Community Services Card (CSC), e.g. A3, S3, O3, etc. This article is specifically for those codes where there is a maximum co-payment of $15, as some 3 codes attract different co-payments.

A point of difference between pricing of scripts from non-approved and approved providers is that there are no negative subsidy prices for 3 coded scripts as described in Negative Claim Items. This is why the pricing on the prescription entry screen is labelled *CoPay NSS:

In the above example, the patient Price is $15, comprised of $2.50 container and $7.50 dispensing fees (set in Standard price parameters, see below), the medicine cost of $2.56 plus an adjustment. This Adjust is the amount required to make the patient cost $15.

As soon as the subsidised price, calculated from the current Integrated Community Pharmacy Services Agreement (ICPSA), is greater than $15, Toniq will indicate this by labelling the pricing as *Subsidy:

In the above example, the pharmacy will receive $15 co-payment from the patient plus $26.56 in a claim for this script item.

Standard price parameters

To set how non-approved provider scripts price when under $15, from the main menu of Dispensary, go to 7. Administration, 1. Setup, then 4. Standard price parameters:

Note: all figures above are examples and not indicative of what should be set or is set at any pharmacy.

If Round to CoPay if within is set to 15 then scripts from non-approved providers will automatically price to the full $15.

If Round to CoPay is not $15 then the other settings are applied. Pharmacy can add a container, after hours, and dispensing fees for whole and part packs. The medicine is priced at the whole pack or broken pack Markup, per what is dispensed. These are all added up: 

Note: there is no Adjust, as the first example above has, because Round to CoPay has been set to 0.

Warning

If both Round to CoPay if within is set to 15 and Markups been set in Standard Pricing Parameters, then the Medicine cost will not reflect the price used in IPCSA pricing. This, plus any fees that have been set may make the Adjust price be negative to get the patient Price to $15: