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 referencing

Cost-plus

Others (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

Framework

Relevance

Methodological 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