Following our review of insurers statements on coverage of Keytruda (Pembrolizumab) we have been asked to detail the differences between the non-Pharmac coverage offered by each insurer. Quality Product Research does that, so here are the main sub-score limits and policy wording for each company that offer Non-Pharmac Drugs cover. Below the table is the actual wording of the relevant section for each insurer. Please note that the item weighting and amount scores are applied after this step in the scoring process – this just highlights the difference in eligibility. If you are interested in more detail please contact Alan, Kelly, or Nikki in the Quotemonster team for more details.
Accuro
Smartcare+ ACC6380-08/14, Page 8
Non-PHARMAC subsidised drugs
Non-PHARMAC subsidised drugs are included within the benefit maximums that apply to the surgical and non-surgical benefits, whichever is applicable for the required treatment.
Covers the costs of reasonable and customary charges associated with accessing the most effective treatment available, irrespective of whether that treatment qualifies for a government (or quasi-government) subsidy, such as PHARMAC funding.
Reimburses the costs of all drugs registered by Medsafe for use in New Zealand where:
• the treatment is prescribed by a specialist as the appropriate medical treatment for the condition, and
• the treatment and/or condition are not excluded elsewhere in this policy document, and
• the drug is being prescribed within the guidelines set by Medsafe.
Covers the costs of these drugs over and above any government (or quasi-government) subsidy. All costs under the non-PHARMAC drugs benefit are included within the benefit maximums of the Hospital and Surgical+ base plan.
AIA
REAL Health, 12/10/2015, Page 11, Section B2
2 We will reimburse up to $500,000 per Life Assured per Policy Year the amount for Usual, Customary and Reasonable expenses incurred in an Approved Facility where the Life Assured has been diagnosed with cancer by a Registered Medical Specialist. An Annual Excess applies. Cancer treatment includes but is not limited to: – Surgery – Oncologist consultations – Diagnostic imaging and tests – Chemotherapy – Radiotherapy – Prostate brachytherapy – Breast Reconstruction following a mastectomy performed by a Registered Medical Specialist in an Approved Facility, approved by AIA New Zealand.
We may approve additional treatments at Our sole discretion.
PHARMAC Medicines and Non PHARMAC Chemotherapy Medicines (including Cancer Immunotherapy medicines) are covered in New Zealand, subject to prior approval by AIA New Zealand, meeting AIA New Zealand’s criteria and Benefit maximums.
nib
UHMPD 01/10/2015, Page 25, Sections 4 & 5
4. Non-PHARMAC Funded Drugs in Hospital Benefit
This Benefit covers the costs of drugs that are Medsafe approved for use in a Recognised Private Hospital (see Medication provided in hospital and at home on page 18).
Benefit limit
– The maximum we will pay is included in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies).
Additional terms
– For drugs issued for the sole purpose of use at home after Admission (see Non-Pharmac Funded Drugs at Home Benefit below).
– Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies).
– Benefits are not payable if the drug is not approved by Medsafe.
5. Non-PHARMAC Funded Drugs at Home Benefit
This Benefit covers the costs of drugs that are Medsafe approved up to six months after Admission approved by us (see Medication provided in hospitals and at home on page 18).
Benefit limit
– The maximum we will pay is included in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies).
Additional terms
– For drugs issued during Admission (see Non-Pharmac Funded Drugs in Hospital Benefit above).
– Benefits are only payable providing the drug are Medsafe approved and is directly relate to that Admission.
– Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies).
Partners Life
Personal Protection, Private Medical Cover, V12 (1 April 2015), Page 5, Section 4.3
4.3 Non-PHARMAC Subsidised Drugs Benefit
Partners Life recognises that purchasing private medical cover should allow the life assured to access the most effective treatment available, irrespective of whether that treatment qualifies for a government (or quasi-government) subsidy, such as PHARMAC funding.
As a result, Private Medical Cover reimburses the costs of all drugs registered by Medsafe for use in New Zealand where:
• The treatment is prescribed by a Specialist as being the appropriate Medical Treatment for the condition; and
• The treatment(s) and/or condition(s) are covered elsewhere in this Protection Benefit Sheet; and
• The drug’s cost is covered under the Surgical Benefit, Non-Surgical Benefit or Serious Illness Benefit; and
• The drug is being prescribed within the guidelines set by Medsafe.
Partners Life will cover the costs of these drugs over and above any government (or quasi-government) subsidy. All costs under this Non-PHARMAC Subsidised Drugs Benefit are included within the benefit maximums that apply to the Surgical, Non-Surgical or Serious Illness Benefits, whichever is applicable for the required treatment.
Southern Cross
VIP1, 21/07/2014, Page 3
Cancer Care
Chemotherapy
$60,000 per Claims Year
Treatment provided by a Medical Practitioner Band III or IV vocationally registered in oncology in private practice, either as an out-patient or in a Certified Private Facility or other Southern Cross approved facility in New Zealand. Includes the cost of materials, Chemotherapy Drugs, hospital accommodation (on a single room basis, excluding suites) and ancillary hospital charges.
Maximum also includes reimbursement of the actual cost up to $10,000 per Claims Year for non-Pharmac Approved MedSafe indicated chemotherapy drugs.
Sovereign
712 PH-UMB version 2 Sovereign Private Health, 10/2015, Page 9, Section F
Chemotherapy treatment provided by a registered medical specialist in an approved facility. Includes the cost of materials, hospital accommodation and ancillary hospital charges. Includes the cost of Pharmac and non-Pharmac approved MedSafe indicated chemotherapy drugs, subject to Sovereign criteria. Prior approval must be obtained before the procedure takes place.