A number of high cost drugs, devices, procedures and products have been excluded from the scope of the national tariff of payment by results. ‘High cost drugs’ are typically for specialist use and the commissioning arrangements for these drugs is to ensure their safe, effective and appropriate use within available funding. These drugs are commissioned by:
- NHS England or
- Clinical commissioning groups (CCGs)
A comprehensive list of medicines not reimbursed through the national prices and directly commissioned by NHS England is available here.
A summary of PbR excluded from tariff drugs commissioned by CCG or NHSE is available here (2020-21).
Individual Funding Requests
If an individual falls outside the range of services and treatments that the CCG/NHSE has agreed to commission then an Individual Funding Request can be made by a clinician, on behalf of a patient, to fund healthcare. The responsibility for demonstrating clinical exceptionality* lies with the requesting clinician and based on the information provided the CCG/NHSE must decide whether or not to support this view and agree to fund the request.
An individual funding request (IFR) must also be submitted when the commissioning intentions specify that an IFR must be submitted for that particular drug and indication.
*Clinical Exceptionality: There is a clinical commissioning policy, NICE Technology Appraisal (TA) guidance or Highly Specialised Technology (HST) Appraisal for this condition but when compared to the general population of patients with the condition and (if relevant) at the same stage of progression, the patient is presenting with significantly different clinical features. As a result of these differences the patient is likely to receive material additional clinical benefit from treatment than would be plausible for any typical patient.
There is not a relevant clinical commissioning policy, NICE Technology Appraisal (TA) guidance or Highly Specialised Technology (HST) Appraisal guidance in place for the management of the patient’s condition or combination of conditions, and the patient’s clinical presentation is so unusual /rare that they could not be considered to be part of a defined group of patients in the same or similar clinical circumstances for whom a service development should be undertaken.*
Individual Funding Requests of PbRex (‘high cost’) drugs flow chart + IFR form links Nov 2020
A technical document is available which describes the prescribed specialised services, some of which are directly commissioned by NHS England and some by CCG’s. This Manual can be accessed here.
For a detailed list of the NHS National Tariff Payment System click here.
Cancer Drugs Fund
NHS England are the responsible commissioners for the Cancer Drugs Fund (CDF). The CDF is a source of funding for cancer drugs in England To see which treatments are currently funded by the CDF, please see the Cancer Drugs Fund List.
Patient Access Schemes are pricing agreements proposed by pharmaceutical companies to enable patients to gain access to high cost drugs that are not likely to be approved by NICE for use in the NHS because they are expensive and do not have a significant benefit over existing treatments. For a list of technologies with approved Patient Access Schemes click here.
Pharmacy Contact Details
High Cost Drugs Homecare Co-ordinator
Tel: 01737 768511 ext: 6250
High Cost Drug In House Co Ordinator
Telephone: 01737 768511 ext:7294
R&D and Formulary Lead Pharmacist
Tel: 01737 768511 ext: 6251