Exceptional Circumstances

Read the Exceptional Circumstances Information Sheet (6 pages, 131 KB).

Exceptional Circumstances offers people access to medicines that aren't otherwise funded through the Pharmaceutical Schedule, or through DHB Hospitals. Separate schemes, with distinct criteria, operate for community, hospital and cancer medicines.

Community Exceptional Circumstances

The Exceptional Circumstances scheme was established to provide funding for medicines in circumstances where the provision of a funded medication is appropriate, but the funding is not able to be provided through the Pharmaceutical Schedule. To qualify for Exceptional Circumstances approval, people have to meet one of the following criteria:

The condition must be rare, or
The reaction to alternative funded treatment must be unusual, or
An unusual combination of circumstances must be present.

Rare and unusual are considered to be in the order of fewer than 10 people nationally.

Should the entry criteria be met, the application is then further examined under supplementary criteria, assessing suitability of the pharmaceutical, clinical benefit, the cost effectiveness of the treatment, and the patient’s ability to pay for the treatment. Where these documented criteria are met a fully funded pharmaceutical will be made available.

Applications should be made on the standard application form or by writing to the address below to request forms be posted.

Applications for patients should be directed to:

Exceptional Circumstances Panel Coordinator
PHARMAC
PO Box 10-254
Wellington.

Hospital Exceptional Circumstances (HEC)

HEC has been running since July 2003. This is the mechanism that enables DHB hospitals to fund medicines in the community that are not funded through the Pharmaceutical Schedule. The sole criterion for approval under HEC is that funding the medicine by the DHB hospital is more cost effective for the hospital than the most likely alternative intervention or outcome.

Cancer EC

Cancer EC was set up in 2005. This mechanism allows DHB hospitals to fund, on application to PHARMAC, cancer medicines that are not funded through the Pharmaceutical Cancer Treatments “basket” – a list of cancer medicines that all DHB hospitals must fund.