list of reimbursable pharmaceuticals ppri project christine leopold gesundheit Österreich gmbh
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Warsaw 29 October 2007 1
Pharmaceutical Pricing & Reimbursement Information ÖBIG
List of reimbursable pharmaceuticalsPPRI Project
Christine LeopoldGesundheit Österreich GmbH
PPRI ConferenceWarsaw, 29 October 2007
Warsaw 29 October 2007 2
Pharmaceutical Pricing & Reimbursement Information ÖBIG
Product-specific most common (e.g. AT, EL, IT, SK, SI)
Example Austria main criterion is the product
assessment of the product by pharmacological evaluation, medical-therapeutic evaluation, health-economic evaluation
Disease-specific Baltic states, sub-scheme in some countries (BG, CZ, FR, IE) Example Latvia
Main criterion is the underlying disease which shall be treated „List of reimbursable diseases“ Same pharmaceuticals may be reimbursed at different reimbursement rates for the
treatment of different diseases
Type of reimbursement - eligibility criteria
Warsaw 29 October 2007 3
Pharmaceutical Pricing & Reimbursement Information ÖBIG
Patient-group-specific CY, IE, MT; TR
Example Malta and Cyprus Specific population groups are eligible for reimbursement e.g. children, elderly person,
handicapped persons or low income population.
Non-eligible persons have to buy health services and pharmaceuticals out-of-pocket
Consumption-based DK and SE
Example DK Level of reimbursement depends on the expenses for pharmaceuticals of a patient within a
certain period of time (e.g. a year)
Patient pays the full cost of his/her reimbursable medication up to a threshold of about € 64.- per a 12 month period. After passing this threshold, the reimbursement rate rises gradually
Type of reimbursement - eligibility criteria
Warsaw 29 October 2007 4
Pharmaceutical Pricing & Reimbursement Information ÖBIG
Pricing proceduresExternal price referencing Internal price referencingCost-plusOthers (e.g. indirect price control)
See PPRI Glossary, http://ppri.oebig.at
Pricing of reimbursable pharmaceuticals – pricing procedures
Warsaw 29 October 2007 5
Pharmaceutical Pricing & Reimbursement Information ÖBIG
External price referencing(international price comparisons)Used in nearly all Member StatesFor at least a range of pharmaceuticals
Focus on a few countries (exceptions: AT, BE),mostly MS/neighbouring countries
FrameworkRelevanceMethodological issues
Pricing proceduresMethodology to determine a price
Warsaw 29 October 2007 6
Pharmaceutical Pricing & Reimbursement Information ÖBIG
Internal price referencing often in connection with reimbursement
Cost-plus For locally-produced pharmaceuticals
(CZ, CY, EL, SK, exceptionally - UK)
Others Indirect price control - PPRS (UK) Agreed prices - Price competition (SK)
Pricing proceduresMethodology to determine a price
Warsaw 29 October 2007 7
Pharmaceutical Pricing & Reimbursement Information ÖBIG
Define which pharmaceuticals are considered as reimbursable
Positive lists in all EU Member States (exemption EL)
Negative lists seldom used (FI - not implemented; ES and UK)
Updating of reimbursement lists Annually Quarterly Every three months As soon as a new pharmaceutical enters the market
Reimbursement lists
Warsaw 29 October 2007 8
Pharmaceutical Pricing & Reimbursement Information ÖBIG
Share of reimbursable pharmaceuticals 2005
Cost-Containment in Europe
6%
19%
40%
51%
59%64%
67%71% 73%
83%
99%
0%
20%
40%
60%
80%
100%
120%
LV BG EE PL FI AT HU FR IT PT DK
Source: PPRI 2007
Warsaw 29 October 2007 9
Pharmaceutical Pricing & Reimbursement Information ÖBIG
All pharmaceuticals on the positive list(s) are 100% reimbursed only in AT, IT, IE, MT, NL, UK
Percentage reimbursement rates according to severity of disease for which the
pharmaceutical is used
Further co-payments (e.g. prescription fees) Reference price systems
What does reimbursable mean?
Warsaw 29 October 2007 10
Pharmaceutical Pricing & Reimbursement Information ÖBIG
Positive list includes 5.744 pharmaceuticals (1.8.2006) ->100% reimbursement for all pharmaceuticals on the list
Reimbursement in Austria
Yellow Box
Drugs not qualifying for automatic reimbursement.Inclusion based on certain criteria (disease group..)ANDafter prior approval from the chief medical officerreimbursable.
Green Box
Drugs qualifying for automatic reimbursement. Inclusion of a drug in this box may be based on certain criteria relating to drug usage, suchas disease group, age of patient and mode of application.
“light yellow“ Box
Drug on prevailing conditions reimbursableBUTEx-post control by the chief medical officer
List of not reimbursable drugs-> possibility of individual reimbursement after approval by the chief medical officer
Red Box
As soon as an applicationis filed, the correspondingdrug is included in this box Maximum: 24 (respectively36) months
after prior approval from thechief medical officerreimbursable
Code of Reimbursement (Positive List)
Warsaw 29 October 2007 11
Pharmaceutical Pricing & Reimbursement Information ÖBIG
Criteria Product-specific criteria (Pharmacological evaluation,
medical-therapeutic evaluation, health-economic evaluation)
Pricing procedure External price refercening: EU average price
Updating of the list twice per year (1 January and 1 July) Individual reimbursement
In case were no treatment alternative is available Ex-ante or ex-post approval is necessary On average 45.000 prescriptions per month
Reimbursement in Austria
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