Epidiollex, an Epilepsy Treatment, Covered by Health Insurance... Patient Burden Reduced to 1/10

6th Health Insurance Policy Deliberation Committee Meeting
New Health Insurance Coverage for 2 Products Including Epidiolex
Cost Committee Newly Established Within Health Insurance Policy Deliberation Committee

Kang Do-tae, the 2nd Vice Minister of Health and Welfare, is presiding over the 6th Health Insurance Policy Deliberation Committee plenary meeting held on the 26th at the Seoul office of the Health Insurance Review and Assessment Service in Seocho-gu, Seoul. (Photo by Ministry of Health and Welfare)

[Asia Economy Reporter Kim Ji-hee] Starting next month, health insurance will be applied to the oral solution of the severe epilepsy treatment drug 'Epidiolex'.

The Ministry of Health and Welfare announced on the 26th that it held the 6th Health Insurance Policy Deliberation Committee (HPC) meeting of 2021 and discussed new drug listings, the formation and operation of the Medical Cost Analysis Committee, and monitoring and performance evaluation plans for the management fee of dedicated inpatient specialists.

First, the HPC decided to newly apply health insurance to two drugs: Epidiolex oral solution and the type 2 diabetes treatment drug 'Zultophy FlexTouch Injection'. The upper limit price for Epidiolex oral solution was set at 1,395,496 KRW per bottle, and for Zultophy FlexTouch Injection, 39,487 KRW per pen. This will improve access to new drug treatments and reduce patients' medical expenses.

The annual medication cost for Epidiolex oral solution without insurance is about 20 million KRW, but with health insurance applied, the annual patient burden is reduced to about 2 million KRW (applying 10% co-payment under the special calculation disease). For Zultophy FlexTouch Injection, the annual medication cost without insurance is about 590,000 KRW, which decreases to 180,000 KRW (applying 30% co-payment) with health insurance coverage.

The Ministry of Health and Welfare stated, "Epidiolex oral solution will be newly covered by health insurance starting April 1, and Zultophy FlexTouch Injection will be covered from May 1, considering the domestic supply schedule of the pharmaceutical company."

Additionally, to verify and utilize medical cost and revenue data from medical institutions, a 'Medical Cost Analysis Committee' under the Health Insurance Policy Deliberation Committee will be newly established and operated. Currently, the National Health Insurance Service is building an accounting investigation system for panel institutions, but there has been a limitation in utilizing it for health insurance policy decisions due to the lack of agreed calculation standards and methods.

Therefore, the Ministry plans to operate the committee to publicize various issues for objectivity and discuss them from a professional perspective. The committee will consist of up to 18 members: 3 experts recommended by subscribers, 6 experts recommended by providers, 6 academic and public interest members, and 1 ex officio member from the Ministry of Health and Welfare, National Health Insurance Service, and Health Insurance Review & Assessment Service. The term is three years, from June this year to May 2024.

The committee plans to disclose analysis results annually through regular reports. The existing Relative Value Planning Group will operate as a complementary system to utilize this for resolving imbalances in medical fields. The Ministry said, "By sufficiently verifying and enhancing credibility using agreed standards for medical institution cost data, we will support the basis for operating the Health Insurance Policy Deliberation Committee in the future."

Meanwhile, the meeting also discussed monitoring and performance evaluation plans for the management fee of dedicated inpatient specialists. The management fee for dedicated inpatient specialists entered the regular fee system on January 25 this year after a pilot project of over four years.

However, there was an opinion that to fully achieve the originally intended effects of the dedicated inpatient specialist fee, effective and systematic performance evaluation plans should be prepared early in the fee implementation. Accordingly, the HPC discussed multifaceted performance evaluation plans comprehensively considering clinical effects, cost-benefit analysis, and satisfaction of patients and medical staff.

The Ministry plans to regularly monitor the fee claim status for dedicated inpatient specialists and conduct in-depth analysis of detailed medical resources and fee claim status. One year after the fee implementation, the Ministry will evaluate the performance and results of the fee and review effective operation plans.

This content was produced with the assistance of AI translation services.