There are a number of high cost drugs that are excluded from the Payment by Results (PbR) tariff. They are typically specialist, and their use…
There are a number of high cost drugs that are excluded from the Payment by Results (PbR) tariff. They are typically specialist, and their use is concentrated in a relatively small number of centres rather than evenly across all trusts that carry out activity in the relevant HRGs. These drugs would therefore not be fairly reimbursed if they were funded through the tariff. For all excluded activity, commissioners and providers should agree local prices.
The following guidelines, linked to current or expected future use, are intended as an appropriate indication of the drugs that may be considered by the high cost drug steering group for inclusion on the high cost drug exclusion list:
- the drug and its expected associated costs of care are disproportionately high cost compared to the other expected costs of care within the HRG, which would affect fair reimbursement
- there is, or is expected to be, more than £1.5 million spend or 600 cases in England per annum.
Other points to note are that:
- high cost drugs are defined by the cost of the average expected use or unit of the drug. Low cost drugs, irrespective of prescribing volumes, will not be considered for inclusion on the HCD list
- a high cost drug is a high cost drug irrespective of reason for prescription, though DH may choose to exclude certain drugs from PbR for specific indications
- when a decision is made to exclude a high cost drug from PbR, it is added to the list using its British Approved Name (where available).
- if a drug does not appear on the high cost drug exclusion list, then it is within the scope of PbR, unless it is part of an excluded service
- the Oncology Regimens (OPCS 4 Chemotherapy Regimens) list of drugs is maintained by the Oncology Regimens Steering Group.
The link below will take you to the new high cost drugs request portal:
This request portal should not be used for high cost devices or chemotherapy. These have separate portals available from: