Case
Cynthia requests funding for a medication that is likely to help her manage her disability. She provides a letter from her clinician to support her request. The letter highlights that the medication has been trialled by people with disabilities similar to Cynthia, who have observed improved outcomes from the medication.
Would we fund this?
No, we can’t fund pharmaceuticals as we’re not the most appropriate agency to fund this type of support. The health system funds or provides medications and pharmaceuticals as part of a universal service obligation. This includes pharmaceuticals and medications subsidised or made available to all Australians through Medicare and the Pharmaceutical Benefits Scheme (PBS).
Why wouldn’t we fund this?
To work out whether a support is reasonable and necessary for you, we look at the information you give us against the NDIS Funding Criteria. We typically fund supports that:
- relate to your ongoing functional impairment
- enable you to do your daily activities.
This includes supports you get from health practitioners that directly relate to your disability support needs, and help you live in the community and take part in education and employment.
However we can’t fund supports that are more appropriately funded or provided by the health system. This includes pharmaceuticals and medications subsidised and provided by Medicare and the PBS.
We have to think about a number of things when we look at whether is appropriate for us, rather than the health system, to fund or provide a support. We are not responsible for:
- the clinical treatment of health conditions, including ongoing or chronic health conditions
- other activities that aim to improve the health status of Australians, including preventive health and pharmaceuticals
- funding time-limited, goal-oriented services and therapies where the main purpose is related to your health status
This means that if you need or want a medicine not funded through the PBS, we are not the right agency to fund this support, even if it:
- relates to your disability support needs
- is likely to be effective and beneficial
- may be value for money.
What else do we think about?
We are not the most appropriate agency to fund any pharmaceutical, whether prescribed or over-the-counter. Over-the-counter medications, such as paracetamol, are likely to also be a day-to-day living cost we don’t fund.
We are not the most appropriate agency to fund medicinal cannabis products, as these are also pharmaceuticals. If you are eligible, and may benefit from access to medicinal cannabis products outside the PBS, you may be able to get these through an alternative scheme via the Therapeutic Goods Administration. This means the health system is likely to more appropriate.
We are also unlikely to be the most appropriate agency to fund trials of non-PBS-listed medications are also unlikely to be most appropriately funded by the NDIS. These are a ‘time-limited, goal-oriented service or therapy’ where the main purpose related to improving or treating your health status.
Case example
Jenny is 50 years old and has been diagnosed with Multiple Sclerosis (MS). She lives at home with her husband and adult daughter. Jenny is independent, needing very little help with her self-care activities. She does need her husband and daughter to manage all the household domestic tasks.
Jenny is very distressed about the affect her disability has on upon her family. She begins to look into things that might improve her function. Jenny’s neurologist tells her about a preventative medication recently found to have good results with improving the capacity of people with MS. The medication is new, expensive and is currently not funded or subsidised through the PBS.
Keen to increase her independence, Jenny asks us to fund her trial of this medication. With her application, she includes a recommendation from her neurologist that the medication is likely to be both effective and beneficial.
When deciding whether the funding for the pharmaceutical medicine is reasonable and necessary, the planner looks at the information Jenny provides against the NDIS Funding Criteria. In doing so the planner thinks about whether the support:
- is value for money in that its cost is reasonable relative to its benefits and the cost of other relevant supports
- will be, or is likely to be, effective and beneficial for Jenny, with regard to current good practice
- most appropriately funded by us rather than the health system.
In Jenny’s case, the planner decides that:
- we are not the most appropriate agency to fund medication. Preventative medication and pharmaceuticals are more appropriately provided or funded by the health system.
- The NDIS is not responsible for activities that aim to improve the health status of Australians, including providing preventative medication and pharmaceuticals.
- The planner also decides that it is not value for money for the NDIS to fund supports that are the responsibility of another service system even though, based on the clinical evidence from the neurologist, it is likely the medicine would be both effective and beneficial for Jenny.
Despite the fact that the medication was likely to be beneficial and could increase Jenny’s independence, since the medication is not reasonable and necessary, we won’t t fund it.
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