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

The rarity is estimated by the GP to be 1:1000. No material was provided to the
Panel to substantiate the rarity claim. Notwithstanding the lack of corroborating
evidence, 1:1000 is estimated to be 3,500 people suffering this condition in New
Zealand at one time. There are more that 10 people suffering asthma or the
unusual circumstances the GP describes.
The GP did not provide any journal articles to show that Singulair is safe or
effective in these clinical circumstances. No specialist report is provided the
Panel only a discharge summary from Gisborne Hospital and two GP referral
letters.
The Panel refused the Community Exceptional Circumstances claim on the
grounds that asthma is not a rare condition. There is no comment from the
Panel to indicate if the patient’s clinical circumstances are considered rare.
Case No. 7 (OIA Document No. 87) June 2010.
This claim from a GP was on behalf of a woman who was suffering Barrett’s
Esophagus with gastro-oesophageal reflux. The claim was for the drug Losec
(Omeprazole) at a projected cost of $169.00 per year.
The claim made under the criterion that reaction to an alternative treatment is
unusual. The treatments she had tried were Omeprazole, Pantraprazole,
Ranitadine and Famotadine which were all ineffective in controlling her reflux.
The GP states that the rarity factor is unknown.
No journal article is provided to demonstrate that the drug requested is safe and
effective treatment for the condition the patient is suffering. A report from an
investigative procedure, an Oesophagal–Gastro Duodenoscopy, confirmed very
minor evidence of Barrett’s disease and little else was seen. The specialist
requested that the patient remain on Omeprazole.
In essence this claim was about the patient wanting funding for a different brand
of Omeprazole.
The claim was denied. The GP was informed that the claim did not meet the
criteria for Community Exceptional Circumstances in that the condition was not
rare, the response to alternative treatment was not unusual and the clinical
208