Reimbursement Categories of Medicines in European Union Member Countries

Source:  EUROMEDSTAT (http://www.euromedstat.cnr.it/reports/reports_reimbursement_categories.asp)

AUSTRIA

"Heilmittelverzeichnis": Pharmaceuticals listed on the "Heilmittelverzeichnis" (Pharmaceutical List) qualify for automatic reimbursement (100%)

"Chefärztliche Bewilligung": Pharmaceuticals which are not listed on the "Heilmittelverzeichnis" (Pharmaceutical List) are only funded (100%) by the social insurance if they are approved by the health insurance fund (though a so-called "head doctor" of the health insurance fund). According to the ASVG-based guidelines by the Federation of Austrian Social Insurance Institutions for economic prescribing, some remedies must never get an approval by the "head doctor": medicinal wines, mineral waters, tonics, bath oils without proven therapeutic effects, cosmetics, remedies for the cessation of nicotine dependence and for the stimulation and/or intensification of the sex drive. As they are not listed in the "Heilmittelverzeichnis", they are thus exempted from the general reimbursement scheme (negative list)

Legal basis: The social insurance scheme in Austria is based on the General Social Insurance Act (ASVG – Allgemeines Sozialversicherungsgesetz), which covers the majority of employed persons and pensioners. Apart from the ASVG scheme, there are specific laws for civil servants, persons active in a craft or trade, self-employed persons, farmers and notaries.
According to the General Social Insurance Act (ASVG), in Austria all pharmaceuticals are reimbursable, if they are "required for effective and sufficient medical treatment which does not exceed the necessary level" (for a small negative list see below).However, two different types of reimbursement are distinguished: the "Heilmittelverzeichnis" (Pharmaceutical List) and the "chefärztliche Bewilligung" (approval by the "head doctor").

BELGIUM

"Category A"  means Vital Medicines: (e.g. against Diabetes, Cancer, AIDS) 100% reimbursement
(Represent 14.6% of the state expenditures)

"Category B" means Important medicines, for non-life-threatning diseases:
75% reimbursement for normal insurees (with a maximum per package 9.79 EUR)
85% reimbursement for underprivileged insurees (orphans, widows, invalidated persons) (with a maximum per package 6.57 EUR)
(Represent 83,3 % of state expenditures)

"Category C" means Medicines more likely to be comfort medicines
(Represent 2.1 % of state expenditures)

"C" means Normal insurees: 50% Reimbursement (Max 12,24 EUR)
Underprivileged: 50% Reimbursement (Max 9,79 EUR)

"Cx" means 40% Reimbursement (no max.)

"Cs" means 20% Reimbursement (no max.)

"Category D" means Not reimbursed medicines

Practically all reimbursed medicines are Prescription only medicines. An important part of the non-reimbursed medicines are prescription only medicines (e.g. benzodiazepines).

DENMARK

Reimbursement for persons older than 18 years
0 %; 0 – 68.60 Euro
50 %; 68.60 – 165.40 Euro
75 %; 165.40 – 386.60 Euro
85 %; Over 386.60 Euro

Reimbursement for persons younger than 18 years
50 %; 0 – 68.60 Euro
50 %; 68.60 – 165.40 Euro
75 %; 165.40 – 386.60 Euro
85 %; Over 386.60 Euro

FINLAND

"Peruskorvausluokka" means Basic Refund Category. Patient pays EUR 10 plus 50% of the remaining costs of preparations purchased on one occasion. When the Pharmaceuticals Pricing Board accepts a reasonable wholesale price for a medicine, this is automatically reimbursed in the basic refund category

"Merkittävät ja kalliit lääkkeet" means Significant and Expensive Drugs: Sub-group of the Basic Refund Category To qualify for a refund of a medicine belonging to this group, the patient has to prove his/her need for such medication by providing a doctor's certificate. Without this certificate, the medicine can't be reimbursed. The sub-group includes, for example, certain drugs used in the treatment of MS, erectile dysfunction and obesity. Council of State determines which medicines belong to this sub-group

"Alempi erityiskorvausluokka" means Lower Special Refund Category. Patient pays EUR 5 plus 25% of the remaining costs of preparations purchased on one occasion. The patient has to prove his/her need for this medication by providing a doctor's certificate. Without this certificate, the medicine is reimbursed in the Basic Refund Category. Includes drugs for chronic conditions such as asthma, hypercholesterolemia, hypertension and ulcerative colitis. Council of State determines both diseases and individual medicines belonging to this Category

"Ylempi erityiskorvausluokka" means Higher Special Refund Category. Patient pays EUR 5 of the costs of preparations purchased on one occasion. The patient has to prove his/her need for this medication by providing a doctor's certificate. Without this certificate, the medicine is reimbursed in the Basic Refund Category. Includes drugs for the treatment of life threatening and severe chronic diseases, including cancer, diabetes and some psychotic disorders. Council of State determines both diseases and individual medicines belonging to this Category

"Lisäkorvaus" means Additional Refund: If person's annual medicine costs exceed a certain limit (EUR 601 in 2003), the remainder is refunded entirety

FRANCE

"100%" means Medicines used in life threatening conditions (diabetes, AIDS, cancer)

"65%" means Reimbursed medicines that do not belong to the group 100% or to the group 35%

"35%" means Medicines used mainly for non-serious conditions (acute conditions)

"0%" means OTC drugs

GERMANY

"Verordnungsfähig" means Reimbursed. These drugs are reimbursed according to the German positive list

"Nicht verordnungsfähig" means Not-reimbursed. These drugs are not reimbursed according to the German positive list

GREECE

Syntagografoumena farmaka
A list of prescription medicines includes all reimbursed medicines. The list is updated periodically by the Ministry of Health

Mi syntagografoumena farmaka
Medicines for which no prescription is required are Not Reimbursed medicines.

ITALY

"Classe A": This class includes "essential medicines and medicines for chronic diseases". All the medicines included in this category are fully reimbursed (100% of their price) by the National Health Service. This means that the patient receives by the pharmacist the prescribed medicine paying only a ticket (around 1-2 euro) . Lower income subjects are ticket-free. Patients with specific social diseases (diabetes, hypertension and other CV diseases, epilepsia, cancer, etc) are ticket-free for all the medicines needed to treat the disease. (i.e an epileptic patient is ticket-free for his antiepileptic medicine, but he must pay the ticket for an antibiotic)

"Classe A con nota CUF": The medicines included in this category are fully reimbursed (100% of their price) by the National Health Service for some specific diseases only.If the medicine is prescribed for a disease not included in the Nota CUF (list) then it is not reimburse The aim of this system, hardly criticised by pharmaceutical companies, is to limit both expenditure and inappropriate utilisation. Note CUF could be defined as guidelines for the appropriate use of medicines and they must be considered an important effort of rationalising GP prescriptions

"Classe C" : The medicines included in this class are not reimbursed by the National Health System. The class includes: medicines for minor ailments (cold, cough, etc) poor value medicines without a well established activity medicines which use is discouraged (benzodiazepines) single trade names with a very higher price as compared with lower price competitor Basically, all the non prescribed medicines are not reimbursed. Some prescribed medicines can be not reimbursed

A former "Classe B" with reimbursement to 50% and a limited number of products was cancelled in the year 2000.

NETHERLANDS

"Annex 1a (WTG-producten)": For those products which are therapeutically interchangeable, a reference price system exists. This so called "clustering" is based on the following criteria: Range of indications Route of administration Absence of clinically relevant differences in efficacy and side effects to Whole patient group or different patient age groups To be used in the same age groups. Within a cluster of comparable products a reimbursement limit is calculated, based on the prices of 1998/IV. In contrast to the above mentioned Medicinal Products Prices Act the price of a pharmaceutical product can exceed this reimbursement limit. The difference has to be paid by the patient. In reality most products are priced on or below this limit, so although theoretically possible co-payment is almost non-existing. 96% of prescriptions are totally reimbursed. Clusterable products are published on the positive annex 1A

"Annex 1b (WTG-producten)" : Products which can not be clustered, but are reimbursed, are published on 1B. This annex 1B has no reimbursement limits. Conditions for placement on annex 1B are: Therapeutic value: the new product is compared with the present standard therapy for that indication with respect to: Effectiveness and/or efficacy; Side effects; Less important items are: Applicability; User-convenience Experience; Quality of Life. A lower therapeutic value leads to a negative reimbursement decision. (Cost) efficiency: At this moment only direct medical costs of the new product is compared to present standard therapy for that indication. At this moment the system is in transition to include pharmaco-economic data into the comparison. If costs are lower or comparable a positive decision is taken. If costs are higher in combination with a higher therapeutic value, the Minister of Health will decide based on the interest of public health

"Annex 2 (WTG-producten)": In some cases extra constrains on reimbursement are necessary. These extra conditions are published on annex 2. Examples of conditions are: Limitation in patient population; Strict treatment protocol; Prior authorisation by health care insurer; Limited prescriber groups

NORWAY

"Blue prescription" means Reimbursement not connected only to the medicine, but based on indication – main rule. Medicine expenses in chronic diseases with long-term treatment are reimbursed. Usually 64 % reimbursed. All expenses over 48 Euro/3 months are covered. 100% reimbursement for children<7 years old

"White prescription" means Usually not reimbursed

PORTUGAL

"Escalões de Comparticipação": There are four normal levels of reimbursement : Level A : 100% Level B : 70% Level C: 40% Level D: 20%. The classification of the medicinal products in the different reimbursement categories depends on its therapeutic classification, considering that therapeutic groups and sub-groups have been previously integrated in the different categories. Level D ( 20%) is a temporary reimbursement period and should be reserved for the medicinal products that for public health reasons need to be in the market to benefit patients but are still under assessment ( pharmacoeconomic study). Reimbursement elegibility is based on the characteristics of a medicinal product, namely : Inovative medicinal products that are supposed to fill a therapeutic group gap: Need to demonstrate higher efficacy and/or tolerance compared to existing similar products New form, dosage or package of a product already in the reimbursement list: Need to demonstrate therapeutic advantage and economic benefit Products not characterised as significant therapeutic innovation and not identical to products already in the list: Need to demonstrate therapeutic advantage and economic benefit Products with more than one active substance, one of them existing as a separated product in the market Need to demonstrate the therapeutic benefit of the combined product compared to the active substances administered separetely. The price of combined product cannot be higher than those of the products having the isolate composite substances. Products having more than one substance, no one existing as separate products in the market: Need to demonstrate therapeutic advantage

"Regimes Especiais de Comparticipação" : In the case of pensioners whose income is not higher than the national minimum wage, an extra 15% is reimbursed in the case of the non fully reimbursement categories, reaching a level of 85, 55 and 35 per cent respectively

"Comparticipação dos Genéricos": For generic medicines there is an extra 10% added to the different reimbursement levels. The reimbursement rates for generics are therefore: 100%; 80%, 50% and 30% for the general system, and 100%, 95%, 65% and 45% for the pensioner whose income is not higher than the national minimum wage

SPAIN

"Pensionistas (receta roja)": This category includes people > 65 years-old, retired and handicapped people. They do not pay for medicines

"Activos (receta verde)": This category include active workers. They pay 40% of medicine price

"Enfermedad laboral o accidente de trabajo (receta azul)": Here are included people who suffer an industrial accident or occupational diseases. They do not pay for medicines

"MUFACE (Mutualidad General de Funcionarios Civiles del Estado)": MUFACE is a mutuality which includes civil servants; they pay 30% of the medicines prices

"ISFAS (Instituto Social de las Fuerzas Armadas)": ISFAS is a special regimen that includes military personnel; they pay 30% of the medicines prices

"MUGEJU (Mutualidad General Judicial)": MUGEJU is a mutuality which includes civil servant from the Justice Administration; they pay 30% of the medicines prices

"Síndrome Tóxico" : People who was affected by the toxic syndrome in Spain. They do not pay for the medicines

"Campaña Sanitaria" : It refers to particular health interventions. People pay 10% of the medicines price up to 2,64

SWEDEN

"Inom läkemedelsförmånen"  means Reimbursed. At the moment this category include all medicines with a negotiated price except for the groups listed below

"Utom läkemedlsförmånen" means Not reimbursed. Medicines without a price negotiated with The national Social Insurance Board. Some cough medicines, medicines for hairloss, nicotine substitute medicines, medicines for erectile dysfunction and obesity medicines are never not reimbursed

Insuline is an exception. Patients belonging to a treatment program receive insuline free of charge.

UK

"Reimbursed": This covers the vast number of medicines in the UK. It includes POM and P medicines, it also include homeopathic medicines or even medicines that are not licensed in the UK but which are legally imported. It also includes items such as, for instance, gluten free bread for coeliac disease. The decision whether a medicine is reimbursed or not is made by a specific Department of Health Committee, but this has been relatively inactive in recent times. There is also an Advisory Committee on Borderline Substances which makes recommendations on "nutriceuticals" and other substances, which might or might not be regarded as medicines. There is a facility for the Minister of Health to decide that a particular drug can be reimbursed only in certain circumstances, e.g. gluten free bread is only available for patients with a clear diagnosis of coeliac disease or sildenafil can only be provided for patients with defined physical or psychosexual disorders. The doctor is required to annotate the prescription that the patient fits into one of these categories

"Not reimbursed": This includes drugs specifically excluded by Department of Health Committee. They are annotated in the British National Formulary as NHS There was a major expansion of this list in 1984 and a slight expansion in 1993. A manufacturer may specifically request that a drug be included on this, for instance, minoxidil for hair loss. An example of a drug which has recently been delisted from this list are nicotine replacement products.

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