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Non-Pharmac Drugs: What They Cost, & How Health Insurance Can Help

In NZ some treatments and medications are publicly funded and some aren't. Learn how the Pharmac system works and what to do when it doesn't cover you.

16 min to read

Anybody familiar with the health system in New Zealand will have heard the name Pharmac come up in discussions about medication and treatment – especially when talking about the cost of access to the latest drugs. Pharmac, or the Pharmaceutical Management Agency, is the government body that decides which medicines to fund. They don’t approve medicines, that’s Medsafe’s role, but they control what drugs are subsidised, administered and available under the public health system.

 
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Pharmac currently subsidises over 2,000 drugs and medical products. But budget constraints and the exorbitant costs of some drugs (see their prices below) prevent the agency from funding many more medicines approved by Medsafe for use by Kiwis.

Today, around 300 funding applications are still waiting to be approved by Pharmac. These unfunded medicines include treatments for:

  • asthma
  • basal cell carcinoma
  • cardiovascular diseases
  • cervical cancer
  • colorectal cancer
  • Crohn’s disease
  • cystic fibrosis
  • diabetes
  • hypercalcaemia
  • hyperparathyroidism
  • leukaemia
  • lung cancer
  • lymphoma
  • multiple sclerosis and spinal muscular atrophy
  • musculoskeletal conditions like osteoporosis, arthritis and gout
  • myeloma
  • ovarian, fallopian tube or primary peritoneal cancer
  • pancreatic cancer
  • prostate cancer
  • renal cancer
  • ulcerative colitis

On top of this waiting list, New Zealand has the smallest number of registered and publicly funded modern medicines when compared to 20 other OECD countries. This further limits our access to the latest treatments for cancer and other chronic diseases.

  • Out of the 441 modern medicines launched in 20 OECD countries between 2011 and 2020, only 131 (30%) were registered in New Zealand and can be prescribed to Kiwi patients.
  • New Zealand publicly funded only 34 out of the 131 modern medicines registered in the country between 2011 and 2020. By contrast, Australia, the UK, and Germany publicly funded 120, 251, and 260 modern medicines, respectively.

Number of publicly funded modern medicines in NZ and selected comparator OECD countries 2011–2020non-pharmac-1-min (1)Source: IQVIA (Commissioned by Medicines New Zealand) November, 2021. ‘A Decade of Modern Medicines: An International Comparison 2011 – 2020’.

  • New Zealand did not publicly fund new modern medicines for arthritis, diabetes, and mental health within the same time period.
  • The country also had among the lowest numbers of publicly funded modern treatments for cancers, cardiovascular diseases, hepatitis C and rare diseases.

Percentage of modern medicines (first registered and launched in the OECD20 2011–2020) publicly funded in key therapy areas, by country.

non-pharmac-2-min (1)Source: IQVIA (Commissioned by Medicines New Zealand) November, 2021. ‘A Decade of Modern Medicines: An International Comparison 2011 – 2020’.

Non-Pharmac drugs and your health

When you’re in good health, the cost of medications may not be a big concern. This is especially true if all the medications you’ve ever had to take have been subsidised by Pharmac.

So why think about non-Pharmac coverage and other health insurance benefits?

  • Because if you become severely ill, your treatment options will be limited to those drugs that are publicly funded.
  • If a new drug that may work best for you isn’t covered by Pharmac, you will be left to your own devices. You will have to independently raise the money to buy these medicines, some of which cost over $1 million per year.
  • On top of this, public hospitals are not allowed to administer non-Pharmac drugs. So you also need to pay to have these administered in a private facility.

Status of Pharmac applications

Below is the status of the applications waiting for Pharmac funding at the time of writing.

  • 122 under ‘Options for investment’: These are applications that will be funded if there is available budget.
  • 47 under ‘Only if cost neutral or cost saving’: These may be funded if Pharmac can generate cost savings or get the medicine at the same price as a currently funded drug.
  • 96 under ‘Recommended for decline’: Clinical experts have recommended that these applications are declined.

We’re all hoping that the government will someday have the budget to cover more medications, or that we’ll personally never have a need for drugs not on the Pharmac-funded list.

Until that day comes, you can be proactive in protecting yourself and your loved ones in case of severe medical issues.

Getting appropriate health insurance broadens your treatment options. So if publicly funded drugs are not effective in your case, for whatever reason, you can afford to try other Medsafe-approved treatments.

If waiting times at public hospitals are long, you can choose to get faster treatment in private facilities.

You can access more health options without worrying about the costs.

Want to know how much non-Pharmac drugs cost and how much financial cover health insurers can provide? Check out the figures below.

The cost of non-Pharmac funded drugs (and their administration) in NZ

Below are some life-extending medications and treatments that are still waiting for funding under the Pharmac system, and their estimated costs.

Some of these applications have been on Pharmac’s list for over six years. Applications can be classified as Options for investment if funds are available but not allocated, while others are already under recommendation to be declined. The key below explains the terms used by Pharmac.

Pharmac priority list status meaning
Options for investment These treatments will be subsidised if funds become available.
Only if cost neutral or cost saving These may be funded if Pharmac can generate cost savings or get the medicine at the same price as a currently funded drug.
Recommended for decline Clinical experts have recommended that these applications are declined.

 

Drug Condition Pharmac priority list status
Nusinersen (Spinraza)

$1.16 million plus four-monthly injections ($125,000 per injection)
Spinal muscular atrophy Type I, II and III Options for investment
Presymptomatic individuals with spinal muscular atrophy Options for investment

Elexacaftor/tezacaftor/ivacaftor and ivacaftor (Trikafta)



Close to $500,000/year

Cystic fibrosis patients aged 6 years and older with at least one F508del mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene Options for investment

Ustekinumab (Stelara)

 

$18,600 for subcutaneous solution (45mg/0.5ml)

Severe Crohn's disease and ulcerative colitis Options for investment

Bevacizumab (Avastin)

 

$50,000

Metastatic colorectal cancer – neoadjuvant treatment for metastatic disease confined to the liver Options for investment
Advanced cervical cancer Options for investment
Advanced ovarian cancer Seeking clinical advice
Relapsed, recurrent glioblastoma multiforme Seeking clinical advice

Pembrolizumab

(Keytruda)

 

Capped at $60,000

Urothelial carcinoma, locally advanced or metastatic, second-line Options for investment
Relapsed or refractory Hodgkin's lymphoma (various conditions) Options for investment
Non small cell lung cancer (various conditions) Options for investment
First-line treatment of recurrent or metastatic head and neck cancer Seeking clinical advice

Eculizumab (Soliris)

 

Over $1 million/year

paroxysmal nocturnal haemoglobinuria (PNH) Options for investment

Abiraterone Acetate

 

$16,700/month

Prostate cancer, metastatic, naive/hormone sensitive Options for investment

Dabrafenib (Tafinlar)

 

$132,000/year

Melanoma, stage III/IV with BRAF V600 mutation Recommended for decline

Ipilimumab (Yervoy)

 

$150,000 for four doses

Melanoma – previously treated unresectable stage IIIC or IV Recommended for decline

Everolimus (Afinitor)

 

$26,000/month

Angiomyolipoma associated with tuberous sclerosis complex Only if cost neutral or cost saving
Tuberous sclerosis (TSC) 2 years & older with refractory epilepsy Only if cost neutral or cost saving
Breast cancer, advanced, hormone receptor positive, HER-2 negative Recommended for decline

Cetuximab (Erbitux)

 

$20,300/month

Colorectal cancer, metastatic, RAS wild-type, left-sided, first-line Options for investment

Raltitrexed (Tomudex)

 

Around $2,000/month

Colorectal cancer, intolerant or contraindicated to fluoropyrimidine due to cardiac toxicity Options for investment

Health insurance cover for non-Pharmac drugs and their administration

Having non-Pharmac funded treatments covered by your health insurance policy means that you and your loved ones have access to more treatment options and expensive, Medsafe-approved drugs that aren’t currently funded under the New Zealand public health system.


And just as importantly, your insurer will cover not just the medicine’s cost but also its administration in private facilities.


With many applications sitting on the Pharmac non-funded list for years, without health insurance cover Kiwis have turned to loans, savings, accessing what should be retirement funds and selling assets to pay for access to treatment.


Health insurance cover that takes your circumstances into account and provides access to non-Pharmac funded drugs can give you a break from worrying about finances while you’re ill.


But how much non-Pharmac funded drug cover do health insurers actually provide? The table below summarises the non-Pharmac benefits of selected health insurance plans, some of which have limits of up to $600,000 per policy year.


Note that insurance plans and providers have different maximum limits and restrictions. Some plans might cost very little but not give you the coverage you need.


So it’s important to consult with an insurance adviser to help you choose a health insurer and a plan that provides enough non-Pharmac drugs cover.


Amounts payable for non-Pharmac funded drugs (surgical and medical treatment) on selected health insurance plans

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Ultimate Health Max

 

SmartCare+

PrivateHealth

 

Private Medical Cover

 

Wellbeing

 

Up to $600,000* per year

 

Up to $500,000* per year

Up to $500,000

per year (chemotherapy / immunotherapy cancer treatments only)

 

Up to $600,000* per year

 

Up to $10,000

per year (chemotherapy only)

 

*Up to the hospital surgical or medical benefit, whichever applies.

These benefits far exceed what you’ll pay for your health insurance.

For example, nib’s Ultimate Health Max plan for a 30-year-old male non-smoker will only cost $19.31 per fortnight. This plan already includes non-Pharmac funded drugs cover of up to $600,000 per policy year.


Want to get a personalised health insurance quote comparison? Contact Policywise to get a FREE, no-obligation quote!

We will compare plans from New Zealand’s top health insurers and show you the ones that offer the best coverage for your circumstances, at the best price.

Instead of limiting your choices to a single health insurer’s offers, Policywise will provide you with the best options on the market. We’ll help you find a plan that offers the right coverage at the best price for you.

Don’t leave your own and your loved ones’ health – and finances – to chance.

The best time to get medical insurance is when you and your family are in reasonable health, and you have no ongoing medical conditions that may affect your insurance cover.

But if you do have pre-existing conditions, we can help you find and compare insurance policies that cover your current health concerns.


Book a meeting with a Policywise Adviser to learn more about non-Pharmac funded drugs cover and health insurance options.

Quickly find the cover that’s best for you

Policywise tells you which health, life or disability insurance best matches your circumstances, 100% free. Talk to one of our insurance advisers to find out which health or life insurance is best for you.

Reference

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Disclaimer: This article is for general information only. Nothing in this blog or on this website is intended as medical, dietary or financial advice. You are advised to consult a financial adviser, health professional, or an appropriate specialist before acting on any information here in. They can factor in your personal circumstances or preferences and help guide your decision-making process.

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