The first assessment reports
have been issued in proceedings concerning immunological medicinal products
conducted under the new rules introduced by the amendment to the Public Health
Insurance Act.
As part of these proceedings,
the importance of vaccination was assessed from several key perspectives:
Societal and social benefits –
the assessment considered not only the impact of vaccination on reducing the
number of infections, but also, for example, the deterioration in children’s
school performance associated with illness and protection against permanent
functional impairment, which in adult patients may affect independence, family
life and overall quality of life.
Economic benefits – the
assessment focused on direct costs, including savings resulting from a reduced
need for treatment and a lower burden on healthcare facilities, as well as
indirect costs, such as loss of household income, productivity losses and reduced
government expenditure on sickness benefits, disability pensions and similar
social benefits.
In these specific cases, prevention through vaccination was
found to be a more economically favourable strategy than the subsequent
treatment of complicated cases of disease.
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The Ministry of Health (MoH) rejected an application to reopen the proceedings.
The applicant argued that, following the conclusion of the original reimbursement review, previously unknown facts had emerged—namely data on the supply and consumption of medicinal products and their market shares. According to the applicant, these data called into question, or even ruled out, the correctness of the established usual daily therapeutic dose (UDTD).
According to the MoH, data on the supply and consumption of medicinal products are known to the State Institute for Drug Control (the Institute) through its official activities and are published by the Institute on a monthly basis. The applicant could therefore have had access to these data already during the original proceedings. Moreover, specific documents containing data on the consumption of the medicinal products concerned in 2022 had formed part of the case file throughout the original reimbursement review. The statutory requirement of “previously unknown facts” was therefore not met.
The MoH further stated that potentially higher consumption of certain strengths of the medicinal products is not decisive for determining the UDTD. Other factors are key to determining the UDTD, including WHO recommendations, the SmPC, scientific literature and clinical guidelines, all of which had been duly assessed in the original proceedings. The applicant’s submission could therefore not have resulted in a different conclusion on the matter.
The MoH therefore rejected the application to reopen the proceedings and did not permit the proceedings to be reopened.
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A continuously
updated overview of decisions issued by SÚKL and the Ministry of Health in the field
of pricing and reimbursement is available on the Pharmeca a.s. website.
The English translation was prepared using the latest available ChatGPT model.
In an abbreviated
reimbursement review triggered by the market entry of the first similar
medicinal product (generic), the State Institute for Drug Control (the
Institute) reduced the base reimbursement for a group of medicinal products
stimulating platelet production following the launch of the first generic
product. One of the
parties to the proceedings, the marketing authorisation holder of a
medicinal product included in the same group but containing a different active
substance than the newly introduced first similar medicinal product, challenged
the therapeutic interchangeability of the individual active substances. The
party submitted new scientific evidence and raised objections regarding safety.
However, the Institute rejected these arguments, referring to previous
administrative proceedings and the legislation governing abbreviated
reimbursement reviews.
In its response,
the Institute stated that the purpose of an abbreviated review is not to
reassess the therapeutic interchangeability of medicinal products. That issue
is addressed within full reimbursement reviews. In the present proceedings, the
Institute relied on conclusions that had already become final in previous full
reimbursement reviews and individual administrative proceedings.
According to the
Institute, the purpose of an abbreviated review under the Act is to ensure a swift
procedure, avoiding extensive scientific debate with the parties in order to
achieve timely savings for the public health insurance system.
Its role is
limited to recalculating reimbursement levels on the basis of the current
external price reference.
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A continuously
updated overview of decisions issued by SÚKL and the Ministry of Health in the field
of pricing and reimbursement is available on the Pharmeca a.s. website.
The English translation was prepared using the latest available ChatGPT model.
The Public Health Insurance Act
establishes a reimbursement cap applicable where the State Institute for Drug
Control (the Institute) decides on temporary reimbursementfor a new
therapeutic indication of a highly innovative medicinal product (VILP)
that already has permanent reimbursement established for another indication. The newly established temporary
reimbursement may not exceed the existing reimbursement granted for that
medicinal product. An exception applies where the product has been assigned to
a reference group containing other therapeutically interchangeable medicinal
products.
According to Section 39d(9) of
the Public Health Insurance Act: “Where proceedings are conducted
to establish temporary reimbursement for a medicinal product that is already
reimbursed from public health insurance in another therapeutic indication
pursuant to a decision of the Institute under Section 39h, the Institute shall
establish temporary reimbursement at an amount not exceeding the reimbursement
determined by that decision under Section 39h. This shall not apply where,
pursuant to a decision under Section 39h, the medicinal product has been
assigned to a reference group or another group of essentially therapeutically
interchangeable medicinal products that already includes other medicinal
products. Where temporary reimbursement has also been established for another
highly innovative medicinal product and the available evidence demonstrates
that it has comparable clinical use and comparable or similar efficacy and
safety, the Institute shall establish temporary reimbursement for the assessed
medicinal product at an amount not exceeding the temporary reimbursement granted
to the highly innovative medicinal product with comparable clinical use and
comparable or similar efficacy and safety, taking into account differences in
dosage and pack size.”
The Institute verifies compliance
with this statutory reimbursement cap in each proceeding concerning
temporary reimbursement. In one such proceeding, where the reimbursement
proposed by the applicant was equal to the permanent reimbursement already
established for another indication, the Institute granted reimbursement in line
with the applicant’s proposal.
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pharmaceutical and medical device information. We also offer flexible services
that can be tailored to your needs at any time.
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need expert guidance.
A continuously
updated overview of decisions issued by SÚKL and the Ministry of Health in the field
of pricing and reimbursement is available on the Pharmeca a.s. website.
The English translation was prepared using the latest available ChatGPT model.
The State
Institute for Drug Control (the Institute) received a joint request from medical
societies to establish increased reimbursement for medicinal products
containing a selected active substance for the treatment of paraphilic
disorders, an indication that falls outside the approved marketing
authorisation (i.e. an off-label indication). In their statement, the medical
societies explained that the request was supported by clinical experience,
scientific evidence, and safety considerations.
The
Institute concluded that the therapy represents the only available treatment
option. Consequently, it did not require the submission of a cost-effectiveness
analysis; a budget impact analysis based on the number of patients reported by
the medical societies was considered sufficient.
Based on the
submitted documentation, the Institute concluded that reimbursement in this
off-label indication is adequately supported by current scientific evidence and
that the therapy constitutes the only available treatment option. It therefore
proposed granting increased reimbursement for this indication as well.
According to
Section 39b(3) of the Public Health Insurance Act: “…The
Institute may establish reimbursement for an unregistered medicinal product
where its use is sufficiently justified by current scientific knowledge and it
represents the only available treatment option, or where its use is
cost-effective compared with available treatment, for the duration of an
approved specific treatment programme. The Institute may also establish
reimbursement for a registered medicinal product for indications not included
in the Summary of Product Characteristics, provided that the use of the
medicinal product is sufficiently justified by current scientific knowledge and
represents the only available treatment option, or where it is cost-effective
compared with existing treatment.”
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Pharmeca a.s.? Feel free to contact us.
At Pharmeca, we help you navigate the complex landscape of
pharmaceutical and medical device information. We also offer flexible services
that can be tailored to your needs at any time.
Our market position and experience allow us to support you whenever you
need expert guidance.
A continuously
updated overview of decisions issued by SÚKL and the Ministry of Health in the field
of pricing and reimbursement is available on the Pharmeca a.s. website.
The English translation was prepared using the latest available ChatGPT model.
As of 1 January
2026, an amendment to the Public Health Insurance Act has entered into force,
introducing, among other changes, new rules for determining the prices of
strategically important medicines. The aim is to prevent supply shortages
in the Czech Republic through a more flexible approach to setting maximum
prices.
For medicinal
products deemed to be in the public interest, the State Institute for
Drug Control (the Institute) now determines the maximum price based on:
·
the average of prices in up to seven of the
lowest-priced countries within the EU reference basket;
·
if the medicinal product is not available in at
least two reference basket countries, prices are compared across the entire EU,
or alternatively against therapeutically comparable medicines in the Czech
Republic or within the reference basket.
To prevent Czech
prices from being driven down by isolated price anomalies, the Institute applies
a number of exclusion rules:
·
if the lowest price in the EU is more than
20% lower than the average of the second and third lowest prices, it is
excluded from the calculation;
·
prices from countries experiencing significant
currency depreciation are excluded where three or more reference prices are
available;
·
prices distorted by government crisis
interventions in other countries are disregarded, provided that the Institute
has received official information about such measures.
The Institute
has already issued a number of decisions establishing maximum prices for
strategically important medicines. However, a concerning trend can be
observed in its decision-making practice. Although this “special regime” is
intended to enhance market stability, many decisions lack sufficiently
detailed reasoning clearly demonstrating that the statutory conditions for
applying this approach have been met.
The new framework
provides the state with a powerful tool for safeguarding the availability of
medicines. Its effectiveness, however, will depend on the transparency and
reviewability of decisions, ensuring that marketing authorisation holders
clearly understand how and why the final price was determined.
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Pharmeca a.s.? Feel free to contact us.
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pharmaceutical and medical device information. We also offer flexible services
that can be tailored to your needs at any time.
Our market position and experience allow us to support you whenever you
need expert guidance.
A continuously
updated overview of decisions issued by SÚKL and the Ministry of Health in the field
of pricing and reimbursement is available on the Pharmeca a.s. website.
In
administrative proceedings concerning a change in the amount and conditions of
reimbursement, the marketing authorisation holder applied for an extension of
the prescribing restriction to one additional medical specialty. Together with
the application, the holder paid only the administrative fee applicable to
cases that do not require a full clinical and pharmacoeconomic assessment. However,
during the proceedings, the State Institute for Drug Control (the Institute)
subsequently requested payment of an additional amount, taking the view that
the case required a comprehensive expert assessment. The
applicant appealed against this approach.
In the
appeal proceedings, the Ministry of Health (MoH) upheld the Institute’s
position, confirming that the administrative fee applicable to proceedings
involving a full expert assessment was appropriate. According to
the MoH, any relaxation of prescribing restrictions facilitates patient access
to treatment, which in itself creates the potential for increased expenditure
from the public health insurance system. This applies even where the absolute
number of patients in the indication does not increase, as treatment patterns
may shift internally in favour of the medicinal product concerned. From the
Ministry’s perspective, such shifts may also result in increased expenditure
from the system. The MoH
therefore concluded that the Institute has a legitimate obligation to properly
assess any potential impact on public health insurance funds and that the
requested administrative fee corresponds to the scope of the assessment being
carried out.
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A continuously
updated overview of decisions issued by SÚKL and the Ministry of Health in the
field of pricing and reimbursement is available on the Pharmeca a.s. website.
The Supreme Administrative Court (SAC) confirmed that a
current cost-effectiveness analysis (CEA) must be submitted in cases where the
requested reimbursement corresponds to the base reimbursement of the
reference group, but exceeds the reimbursement granted to other
therapeutically interchangeable medicinal products. According to the Court, the
decisive factor is whether the proposed change will generate savings for the
system or, conversely, increase expenditure.
In the administrative proceedings, the marketing
authorisation holder applied for an increase in the reimbursement of its
medicinal product. In its view, the request merely sought to align
reimbursement with the level of the base reimbursement established for the
relevant group in a previous review and therefore did not require new economic
evidence. However, both SÚKL and the Ministry of Health insisted on
the submission of supporting analyses and discontinued the proceedings due to
their absence.
According to the administrative authorities, the Public
Health Insurance Act requires a cost-effectiveness assessment and budget
impact analysis whenever the proposed change in reimbursement is expected
to increase expenditure from the public health insurance system and the
requested reimbursement exceeds that of other medicinal products that are
essentially therapeutically interchangeable.
The SAC stated that such analyses are not required where a
medicinal product generates savings for the public health insurance system.
However, where no savings are expected and the proposal results in a negative
budget impact, their submission is necessary. In the case at hand, the proposed reimbursement increase
demonstrably showed signs of an expected negative budget impact (higher costs),
while the requested reimbursement exceeded that of the only therapeutically
interchangeable medicinal product. Since both statutory conditions were met,
the applicant was required to submit a cost-effectiveness analysis.
The Court therefore definitively confirmed the approach
established under the legislation effective since 2022: whenever the requested
reimbursement exceeds that of other therapeutically interchangeable medicines
on the market, its cost-effectiveness must be demonstrated through updated
evidence.
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Our knowledge, your opportunity.
The article is based on publicly available court decisions published on official judicial websites.
The requirement to submit up-to-date cost-effectiveness analyses (CEA) when applying for a reimbursement increase has been confirmed by the Supreme Administrative Court.
