How does the operation of PHARMAC's 'Community Exceptional ...

confirmation that the DHB hospital providing treatment has agreed to fund
the treatment;
confirmation that the condition is considered unusual (and therefore a
decision to treat is unlikely to result in access and inequities across DHBs);
the proposed use has not been considered or is not currently under
consideration by PHARMAC for funding; and
specification on the
o product to be used;
o dose and treatment schedule;
o duration of treatment;
o indication; and
o total cost.
The total cost was to be less than $30,000 over a 5-year period. If the
application is for treatment of $30,000 or over it will be referred for a cost-utility
analysis, followed by a decision from PHARMAC.
This set of criteria was based on peer review within the DHB hospitals to assure
equity of access to pharmaceutical cancer treatments across all the 21 DHBs.
The scheme was intended largely to be self-assessed by the hospital
physicians and relevant DHB officials, provided that the patients met the criteria.
Following this process a PHARMAC staff member considered the application
and the report of the clinicians and advised if the criteria had been met. If the
staff member was unsure, the application was referred to a panel of clinicians.
If that panel decision was unfavourable, the applicant may appeal to the panel
for its reconsideration of the application. If the application is still declined, or not
approved, a request could be made to the Medical Director of PHARMAC for a
further review.
137