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PHARMAC Funded and Non-Funded Medication

Living in New Zealand, we are fortunate to have the benefit of largely free healthcare. Whether it’s an injury or illness, we can generally head to the hospital, be treated for free and given the medications we need to make us well again.

This is partly made possible because of PHARMAC - the only agency in the world of its kind that both decides on which medicines to fund and manages a fixed budget to supply the medicines on the approved list.

While the good outweighs the bad and New Zealanders often don’t have to think about the cost of advanced medicines, there are some cons to the system.

The most significant challenge of course is that not all medication is covered. This is because the budget approved by the government is limited and the decision to fund any medication requires a range of prerequisites to align, such as:

  • Analysis of the cost and benefits as opposed to other alternatives
  • Negotiation with the suppliers for the specific medication
  • Sufficient funds in the budget going forward
  • Approval of the proposal by all stakeholders involved

 

While the ‘dilemma’ is understandable given the limited resources, this does not make it any easier for people whose life-saving medications do not make the cut. Scores of families suffer because their key medications are left off the approved list. Illnesses where non-PHARMAC funded medications are proven to be the better course of treatment in other countries include asthma, Crohn’s Disease / inflammatory bowel, lymphoma, pancreatic cancer, and leukemia among many others.

What happens when the drug you need isn’t approved for funding?

Because hospitals and pharmacies must pay full price for non-PHARMAC funded drugs, they are usually quite expensive to acquire. The request to add Cystic Fibrosis medication, Trikafta, to the approved list is one such situation recently brought to the NZ media’s attention. The cost for a year’s supply of the life-saving drug is estimated to be around $330,000-$500,000. There was also huge distress caused by PHARMAC’s reversal of funding for Keytruda for lung cancer patients when they revealed that they couldn’t fit it into the budget.

As the examples above show, non-PHARMAC funded treatments - including certain life-extending cancer medications - can cost thousands of dollars. And regardless of the cost and the circumstances, without health insurance, Kiwis have to either pay those hefty bills out of their pockets (if they can afford it) or turn to crowdfunding - a very stressful experience during an already difficult time.

How can your health insurance help?

Health insurance provides you with the flexibility and choice when it comes to taking care of your health and choosing the medicines best for your illness. Some health insurance policies offer cover for non-PHARMAC drugs, or at least subsidies while others have this feature as an optional add-on. This is not the case for all health insurance policies however, so it is important to understand what policy you’re signing up for and what’s included.

Coverage of non-PHARMAC medications undoubtedly gives more control over treatment options and grants access to a wider choice.

Working through the details of the policy and deciding on the benefits that would work best for you can seem all a bit too complicated and overwhelming, so it is always good that you speak to an adviser on how you can protect yourself and your loved ones.

Is there another option?

Trauma insurance can provide a lump sum payment if you are diagnosed with up to 70 medical conditions. The most common trauma is cancer, followed by heart related issues and stroke. With the payout of the trauma insurance the option to purchase non-PHARMAC funded medication becomes a lot easier. Talk to us about your options 0800 230 235.