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14-01-2025

From application to patient: the journey of reimbursable medicines in Lithuania

Iliustracija

Every year, new medicines are developed for diseases that are already treated with medicines and for those that previously had no specific treatment. To ensure that patients are treated effectively and do not incur high costs for medicines, they are reimbursed by the Compulsory Health Insurance Fund (CHIF). However, before they can be reimbursed, medicines go through a complex process involving several institutions and a wide team of experts. This process ensures that only effective medicines are reimbursed, at a cost that corresponds to the benefits they generate. This is a responsible use of CHIF funds and helps patients to avoid overpaying for medicines. 

Evaldas Stropus, Head of the Pharmaceuticals Reimbursement Division of the National Health Insurance Fund (NHIF), talks about the journey of a reimbursable medicine from the application to the patient’s hands.

How would you describe that complex process?

In Lithuania, the process of including medicines in the reimbursement system is very similar to other European countries. A number of procedures need to be followed before a medicine can be reimbursed and doctors can prescribe it to patients.

The first step is to include medicinal (active) substances in the list of diseases and reimbursable medicines for their treatment, known as List A. This indicates which active substance is reimbursed for which disease. The list is drawn up by the Ministry of Health and approved by the Minister of Health on the basis of relevant data and procedures.

The inclusion of a medicinal product or active substance in the list of reimbursed medicinal products can be proposed by drug manufacturers, medical societies or patient organisations through a specific application, which is assessed in several stages. The State Medicines Control Authority (SMCA) assesses the effectiveness of the medicine by comparing it with other medicines currently reimbursed. It also assesses cost-effectiveness - whether the cost of treatment with the medicine corresponds to its effectiveness. The NHIF assesses the CHIF’s ability to reimburse the medicine and submits its conclusion to the Commission for the Reimbursement of Medicinal Products and Medical Devices.

This Commission examines the conclusions of both authorities and decides whether or not to include the medicine in List A in accordance with established procedures. Sometimes additional requirements may be imposed, such as reducing the price of the medicine.

If the Commission takes a positive decision to reimburse the medicinal product without the need for additional CHIF funds, the medicinal product is included in the list of reimbursable medicinal products and the NHIF includes the medicinal product in the list of reimbursable medicines. If the reimbursement requires additional funds, the medicinal product is added to the reserve list.

Medicines on the reserve list are already recognised as eligible for reimbursement, but their inclusion on the List A is subject to the financial capacity of CHIF. If, for example, EUR 50 million is needed for reimbursement, but only EUR 30 million is currently available, priority is given to the first medicines on the reserve list until the available amount is exhausted. The remaining medicines remain on the reserve list for the time being and may be added to the list of reimbursable medicines in the next review phase. The list is reviewed twice a year, in the first and third quarter of the year. 

What is the price list for reimbursed medicines?

The NHIF draws up a price list of reimbursable medicines based on the data in List A, but the price list already lists the specific medicines by brand name that will be reimbursed by CHIF. The list is drawn up twice a year: for the first half of the year, it comes into force on 1 January, and for the second half of the year, it comes into force on 1 July. This ensures that the prices of medicines are up-to-date and reflect changes in the market.

The price list is constantly updated, as prices of medicines may fall due to competition between manufacturers or price decreases in European countries. Prices for medicines in Lithuania are based on the average of the three lowest-priced European Union countries. If medicines become cheaper, the patient’s premium is reduced. Patients can choose which medicine they prefer in terms of price. As prices fall, CHIF spending is also reduced and the savings are used to reimburse the basic cost of new medicines.

What is the base price of a medicine?

The CHIF reimburses the basic price of the medicine, not the full price. This is indicated in the price list of reimbursable medicines. The base price is set according to rules approved by legislation, taking into account the average of the lowest prices in the three European Union countries and the prices applicable in Lithuania.

In addition to the basic price of the medicine, the price list also includes the patient’s premium for the medicine. The patient premium is the difference between the retail price of the medicine at the pharmacy and the basic price. The patient has to pay it at his/her own expense if the premium is not covered by the public budget. A pharmacy cannot charge a higher premium for a medicine than the price list.

Such a system allows not only to regulate the prices of reimbursed medicines, but also patients’ payments, thus reducing the financial burden on patients.

Evaldas Stropus. VLK nuotrauka.jpg

Evaldas Stropus, Head of the Pharmaceuticals Reimbursement Division of the National Health Insurance Fund (NHIF photo)

The process is really long. When can doctors prescribe reimbursable medicines for a patient? 

Once a medicine is already on the list of reimbursable medicines and on the price list, it can be prescribed by doctors and, in the cases provided for by law, nurses. Some medicines can only be prescribed by specialists in a particular field if this is specified in the list. For example, some medicines can only be prescribed for the first time by a cardiologist, oncologist or other specialist. The family doctor may continue the treatment according to the rules. If there are no specialist restrictions, the medicine may be prescribed by the family doctor if his/her medical standard allows it.

After a doctor prescribes the treatment, it can be continued by nurses with prescriptions in certain cases, up to a maximum of 12 months. This is very useful for patients, as there is no need to go to the doctor and medicines can be obtained more quickly. It also shortens the queue for those patients who need to consult a doctor.

These rules ensure that medicines are prescribed responsibly and that patients receive the right treatment.

How can patients find out if the medicines they need are reimbursable?

The list of reimbursed medicines and the price list are contained in the Register of Legislation and are publicly available. Patients can easily check the information about a medicine on a separate portal, where they can enter the name of the medicine to see if it is reimbursed.

Patients cannot see certain information, such as which diseases are covered by a particular medicine. This information can be provided by the doctor, who has access to information systems that are only for doctors.

This article is part of the NHIF’s pharmaceutical literacy information campaign „Vaistai nekalba” (Medicines don’t talk). 

(Freepik photo)

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Last updated: 22-01-2025

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