Can some drugs be exceluded from the Drug Payment Scheme?

Straylight

I'm hoping that there might be some pharmacists on this forum who can help me.

My wife and I are currently having fertility treatment. While it's hugely expensive, the one thing that helps keep the cost down a bit is the €144 per month maximum on the Drug Payment Scheme. However when I went to collect the latest batch of drugs yesterday I was told that I'd have to pay an extra €17 because one drug (Pregnyl) is no longer covered by the scheme. I never had to pay any extra for it before and I found it odd as I thought the scheme applied to all drugs. However the pharmacist said that the HSE had recently removed the code for that drug and were no longer covering the cost. Now in the grand scheme of things, and compared to our overall cost, €17 isn't much. But my real concern is that they'd do the same with some of the more expensive drugs. Is this sort of thing common and why does it happen? It seems pretty arbitrary to me to suddenly exclude one drug that had been covered previously.

echo beach

The simple answer to your question is yes.
The HSE decides what drugs to pay for on the various state schemes. There is a long and growing list of exclusions. Nicotine replacement therapy has never been allowed on DPS, although it is allowed on the GMS (medical card). Some time ago all gluten free products and many nutritional products were removed from all schemes. Most recently MS patients have told that a drug that they have been getting has been deemed to be not 'cost-effective' and will no longer be covered.

Your fears of further arbitrary cuts is well justified. This is another of the 'hidden cuts' being imposed on the public. Because each drug removed affects only a small number of people there is no outcry and the complaints can be ignored.

Cedrus

It's hardly arbitrary, there is a panel which reviews the approved list regularly and any drugs which are deemed to be dangerous, ineffective, too expensive or a mixture of these are removed from the list.

A tablet I was on was removed a couple of years back because it was thought to be more expensive than it was effective, I had to pay for it for about six months (6 x €60) until a canadian study linked it to an increased prostate cancer risk and my GP took me off it. Did me a favour really.

Cedrus

The thing that affects far more people is the cut off point. 15 years ago it was only around €60 and most people saved money, at €144 it's not even worth registering any more because my prescriptions are half that.

palmcut

The Government brought in a process that is commonly called generic substitution and reference pricing.
The main aim of this process is to increase generic dispensing in Ireland.
Curently each month the IMB publishes a list of Brand drugs that are suitable for the process. The HSE then implements a pricing structure.
There is a penalty.
After the publication of the drugs and the settlement of prices any patient who wants the brand will have to pay the difference in price between the brand and the generic.
This will lead in some cases to DPS payments + reference pricing being higher than 144 euros.
This is a general explanation. For more details contact your local pharmacy.

Straylight

Cedrus wrote: »

It's hardly arbitrary, there is a panel which reviews the approved list regularly and any drugs which are deemed to be dangerous, ineffective, too expensive or a mixture of these are removed from the list.

The drug in question would hardly be prescribed for my wife if there was evidence to suggest it was considered dangerous or ineffective, and at €17 I wouldn't consider it to be expensive. So yes, it does seem to be arbitrary.

Cedrus wrote: »

The thing that affects far more people is the cut off point. 15 years ago it was only around €60 and most people saved money, at €144 it's not even worth registering any more because my prescriptions are half that.

I agree. The cut-off has increased very sharply over the last few years. In 2010 it was €100, so it's increased by 44% in four years, which seems a bit excessive.

palmcut wrote: »

The Government brought in a process that is commonly called generic substitution and reference pricing.
The main aim of this process is to increase generic dispensing in Ireland.
Curently each month the IMB publishes a list of Brand drugs that are suitable for the process. The HSE then implements a pricing structure.
There is a penalty.
After the publication of the drugs and the settlement of prices any patient who wants the brand will have to pay the difference in price between the brand and the generic.
This will lead in some cases to DPS payments + reference pricing being higher than 144 euros.
This is a general explanation. For more details contact your local pharmacy.

I'm familiar with the generic substitution process, a tablet I take daily was substituted by my pharmacist this month for a generic one. Personally I think it's a great idea and should have been introduced long before now. However according to the HSE website Pregnyl does not have a generic substitute and is not part of the programme, so that's not the reason why I needed to pay extra.

Cedrus

Straylight wrote: »

The drug in question would hardly be prescribed for my wife if there was evidence to suggest it was considered dangerous or ineffective, and at €17 I wouldn't consider it to be expensive. So yes, it does seem to be arbitrary.

arbitrary
ˈɑːbɪt(rə)ri/
adjective
1.
based on random choice or personal whim, rather than any reason or system.
"an arbitrary decision"
synonyms: capricious, whimsical, random, chance, erratic, unpredictable, inconsistent, wild, hit-or-miss, haphazard, casual; More
antonyms: rational, reasoned
2.
(of power or a ruling body) unrestrained and autocratic in the use of authority.
"a country under arbitrary government"
synonyms: despotic, tyrannical, tyrannous, peremptory, summary, autocratic, dictatorial, authoritarian, draconian, autarchic, anti-democratic;

Straylight

I'm not entirely sure what point you're trying to make by posting that, but all it does is confirm my point. As I said, none of the particular conditions that you stated for removing the drug from the list appear to apply, so all that can be deduced from the available evidence is, to quote your definition, that it was based on random choice. Unless, of course, you have something more than a dictionary definition to disprove that.

Kurtosis

Straylight wrote: »

The drug in question would hardly be prescribed for my wife if there was evidence to suggest it was considered dangerous or ineffective, and at €17 I wouldn't consider it to be expensive. So yes, it does seem to be arbitrary.

I'm familiar with the generic substitution process, a tablet I take daily was substituted by my pharmacist this month for a generic one. Personally I think it's a great idea and should have been introduced long before now. However according to the HSE website Pregnyl does not have a generic substitute and is not part of the programme, so that's not the reason why I needed to pay extra.

Straylight wrote: »

I'm not entirely sure what point you're trying to make by posting that, but all it does is confirm my point. As I said, none of the particular conditions that you stated for removing the drug from the list appear to apply, so all that can be deduced from the available evidence is, to quote your definition, that it was based on random choice. Unless, of course, you have something more than a dictionary definition to disprove that.

In fairness, the only questions you asked were was this common and why does it happen, and you've gotten a number of accurate answers. If you want an answer to your specific case, you may need to direct a question towards the PCRS.

There are other reasons why a drug may not be covered under the DPS. If a product which is covered on the DPS becomes unavailable for a time, for example due to a problem with a batch meaning the chain of supply is interrupted, and if there are no generic versions of this product available, a product containing the same drug licensed in another country will have to be imported to ensure patients continue to get their medicines. Such products which are not licensed in Ireland would not be covered on the DPS (or at least not immediately) and so patients would have to pay for these themselves. This has happened with Eltroxin and Pregnyl in the past few years.

Similarly, sometimes a pharmaceutical company will decide not to renew the licence for a product of theirs in Ireland, often due to it being uneconomical in a market as small as ours. While such a product could still be prescribed, imported and dispensed as an unlicensed medicine with the restrictions that entails, it would also usually no longer be covered on the DPS/medical card.

sid40

Straylight wrote: »

I'm hoping that there might be some pharmacists on this forum who can help me.

My wife and I are currently having fertility treatment. While it's hugely expensive, the one thing that helps keep the cost down a bit is the €144 per month maximum on the Drug Payment Scheme. However when I went to collect the latest batch of drugs yesterday I was told that I'd have to pay an extra €17 because one drug (Pregnyl) is no longer covered by the scheme. I never had to pay any extra for it before and I found it odd as I thought the scheme applied to all drugs. However the pharmacist said that the HSE had recently removed the code for that drug and were no longer covering the cost. Now in the grand scheme of things, and compared to our overall cost, €17 isn't much. But my real concern is that they'd do the same with some of the more expensive drugs. Is this sort of thing common and why does it happen? It seems pretty arbitrary to me to suddenly exclude one drug that had been covered previously.

Your pharmacist should ring the PCRS directly to check this. I am open to correction but I think they will find it is covered under the DPS scheme. :-). The pharmacist is correct in saying the code is removed but it will still be covered. Just ask them to contact the PCRS who can clarify the situation and advise the pharmacist what they need to do to claim this medicine in this case.

Nonoperational

I know there have been issues getting Pregnyl recently and a different brand had to be got from a different source. This wouldn't be specifically covered by the DPS but as the poster above said it could be covered as an unlicensed medicine. I'm not regularly dealing with fertility scripts so I can't remember the specifics, but a pharmacy that deals with a lot of them could help you with the information. PM me if you want and I'll give you the name of somewhere that could answer your question.

nino1

Cedrus wrote: »

The thing that affects far more people is the cut off point. 15 years ago it was only around €60 and most people saved money, at €144 it's not even worth registering any more because my prescriptions are half that.

If your prescription is half that you are only paying €12 more than the limit 15 years ago.
If you take inflation into account you are doing better!

huskerdu

Cedrus wrote: »

The thing that affects far more people is the cut off point. 15 years ago it was only around €60 and most people saved money, at €144 it's not even worth registering any more because my prescriptions are half that.

I agree with your first point, but it is still worth registering.

Some day, you could be prescribed something v. expensive on a once off basis, and you will be glad you have the card.

Cedrus

nino1 wrote: »

If your prescription is half that you are only paying €12 more than the limit 15 years ago.
If you take inflation into account you are doing better!

I'd love to see your calculations, especially since you are not considering what my prescriptions cost 15 years ago.

In any case, my comment was more general than just my personal circumstance, I'm OK I'm not complaining for myself (at the moment). More people are affected by the changes in the limit because for many on the scheme €144 represents a greater portion of their disposable income than it would for people who have no interest in the scheme. I also believe that the claim limit changes are more arbitrary than the defined list changes because there is a professional panel who meet regularly to assess the benefits of including/excluding drugs on the defined list, whereas the claim limit is just another budget day compromise.

nino1

Cedrus wrote: »

I'd love to see your calculations

The max you could have paid 15 years ago was €60 as that was the cut off

you now say you pay half of €144

Cedrus wrote: »

€144 it's not even worth registering any more because my prescriptions are half that.

thats €72 so thats where ther €12 difference comes from.

Cedrus

nino1 wrote: »

The max you could have paid 15 years ago was €60 as that was the cut off

you now say you pay half of €144



thats €72 so thats where ther €12 difference comes from.

I also said that

you are not considering what my prescriptions cost 15 years ago

my prescriptions were different then.

They were more expensive.
The drugs repayment scheme covered more than half of the cost.
I now pay the full cost myself.
Like many people, I am NOT better off.

Like you I am capable of doing kindergarden sums, but that is not the true calculation.

Straylight

penguin88 wrote: »

In fairness, the only questions you asked were was this common and why does it happen, and you've gotten a number of accurate answers. If you want an answer to your specific case, you may need to direct a question towards the PCRS.

There are other reasons why a drug may not be covered under the DPS. If a product which is covered on the DPS becomes unavailable for a time, for example due to a problem with a batch meaning the chain of supply is interrupted, and if there are no generic versions of this product available, a product containing the same drug licensed in another country will have to be imported to ensure patients continue to get their medicines. Such products which are not licensed in Ireland would not be covered on the DPS (or at least not immediately) and so patients would have to pay for these themselves. This has happened with Eltroxin and Pregnyl in the past few years.

Similarly, sometimes a pharmaceutical company will decide not to renew the licence for a product of theirs in Ireland, often due to it being uneconomical in a market as small as ours. While such a product could still be prescribed, imported and dispensed as an unlicensed medicine with the restrictions that entails, it would also usually no longer be covered on the DPS/medical card.

You're correct, there have been some very helpful replies, including yours, so thanks to everyone for your help. And apologies if I may have come across as ungrateful in any way, that was not my intention. As I said in my OP, my real concern is if this could happen at any time and we might get stuck with a bill for one of the more expensive drugs, but fingers crossed that things work out this month and we won't need to worry about that.