At Black Swan Analysis we offer you with a robust, transparent and easy-to-use pricing database to help you understand the pricing landscape by seamlessly searching for and comparing pharmaceutical products across European, American and Japanese markets. Our pricing database ‘RxPriceIndex™’ for listing pharmaceutical product prices has recently added Norway reimbursement prices to deliver powerful insights and up-to-date pricing data to suit your needs. In light with this new development, here is a general overview of the Norwegian healthcare system.

General overview

The Norwegian healthcare system is considered to be a semi-decentralised, universal system. There are three levels to the system:

1. Healthcare policy is controlled centrally by the Norwegian Parliament and the Ministry of Health and Care Services (MOH).

2. The responsibility for the provision of healthcare lies with the four Regional Health Authorities (RHA’s). They provide and finance specialist care according local demand. This includes all inpatient care and some outpatient care including prescriptions from community pharmacies.

3. The 422 Municipalities are then responsible for providing and paying for primary healthcare and social services (most out-patient care).

All residents and people working in Norway are entitled to insurance through the National Insurance Scheme (NIS) but healthcare in Norway is not free. All uses of the healthcare system incur a charge; however, it is heavily subsidised and there is an annual national limit to ensure the healthcare system is accessible to everyone.

Price and Reimbursement

The Norwegian Medicines Agency (NoMA) decides on market authorisation for all pharmaceuticals and places them into one of these four categories:

NoMA then sets the maximum price for all accepted drugs at a pharmacy purchase price level (PPP-Level) using external reference pricing.  The Norwegian external reference model country basket includes Austria, Belgium, Denmark, Finland, Germany, Ireland, the Netherlands, Sweden and United Kingdom. The maximum price is set by calculating the mean of the three lowest prices in this pool. Prices for a pharmaceutical product are set freely underneath the maximum price cap set by NoMA.  Furthermore, all manufacturers need to submit a pharmaco-economic evaluation as part of the HTA process.

Norway operates a positive or “blue” list system regarding general reimbursement. NoMA decides within 180 days from the reimbursement application if a product should be reimbursed by the NIS based on these 3 criteria:

The three criteria listed above are weighed against each other when considering if a drug should receive public funding and therefore be added to the positive list.  The positive or “blue” list is then re-evaluated on a monthly basis.   

When generic competition arises in Norway, NoMA introduces a stepped price model.  This model helps to reduce the price of a pharmaceutical through predefined rates, thus reducing total pharmaceutical spending. This stepped pricing model also introduces the maximum reimbursement for a specific active substance thus delineating the maximum reimbursed value for equivalent products.

The stepped price model is defined by two or three steps by which a percentage of the maximum PPP of the original medicine price is taken off.  The first step occurs when first generic competition arises, the second six months after, and the third occurs at least 12 months after the time the second step was implemented.

How does it work?

HELFO, the Norwegian Health Economics Administration is responsible for the reimbursement of all services covered by the NIS. Reimbursement in Norway is split into 2 categories. Primary and specialist care.

Primary care

There are 4 schedules with regards to reimbursement of primary care in Norway:

REIMBURSEMENT CATEGORY REIMBURSEMENT RATEDESCRIPTION
SCHEDULE 262%Medicines on the reimbursement list - reimbursed for specific diagnosis and for 3>months of treatment.
SCHEDULE 3A62%Medicines other than on schedules 2, 4 and 3B. Reimbursement can be granted on submission of an individual application and for >3 months treatment.
SCHEDULE 3B 62% Medicines used to treat rare diseases reimbursed upon submission of an individual application and only for >3 months treatment.
SCHEDULE 4100%Medicines used to treat serious contagious disease such as tuberculosis, syphilis, or HIV/AIDS

General Reimbursement - Schedule 2

Schedule 2 is a positive or “blue” list system. This list consists of medicines approved for reimbursement. For a drug to achieve schedule 2 reimbursement NoMA decides that the drug is price effective for its different individual treatment/therapeutic areas for which the product has market authorisation, the disease area being treated is severe and treatment will be required long term (this is intended as longer than three months). All drugs in this schedule are reimbursed by the NIS at 62%.

A maximum payment of NOK 520 (£39.96) per prescription is also present in Norway. A second higher co-payment price cap supplements the prescription co-payment price cap and it is designed to make healthcare accessible to all residents.  This second cap introduces a maximum spending limit on all healthcare related co-payments of NOK 2258 (£174.04), and includes all reimbursed medicines, lab tests and consultations with specialists or general practitioners. Once a patient reaches NOK 2,258 most additional out of pocket costs are fully reimbursed by the NIS making this the maximum value a patient can spend annually on healthcare in Norway. In 2017 approximately 28% of the population (age over 16) reached this ceiling.

Any products with cheaper generic alternatives are only reimbursed up to the price of the cheaper generic version and the patient pays the difference in price. Doctors are also able to veto this substitution and prescribe the branded version if they believe that there is a valid medical reason for doing so.  

Individual Reimbursement- Schedule 3

Schedule 3 allows patient access to products that are not included in the general reimbursement scheme.  Patients need to apply individually to obtain reimbursed access to the medicine.  Schedule 3 is used when the patient does not elicit a response with schedule 2 products or causes unacceptable side effects in the patient.  Furthermore, access may be granted if the patient characteristics differ from the patient group assessed in the decision for general reimbursement. A product does not need to have achieved marketing authorisation in Norway to be considered for individual reimbursement. All individually approved drugs under schedule 3 are reimbursed at 62%

To contain dangerous illnesses- Schedule 4

Schedule 4 is put in place to allow all patients with severe contagious diseases to receive adequate treatment completely for free. Therefore, all medicines in schedule 4 are 100% reimbursed. This includes all vaccines and medicines used to prevent or treat these severe contagious diseases and unlike the other schedules long term treatment is not a requirement for a drug to be considered for this level of reimbursement.

Specialist care

In the specialist care sector, all medicines are considered fully reimbursed therefore to be paid for by the RHA. The Norwegian Drug Procurement Cooperation (LIS) negotiates prices on behalf of the hospitals and their RHA’s. H-prescriptions (medicines a patient needs upon discharge from hospital) are also fully reimbursed as all specialist care in Norway is available for a nominal out of pocket fee under the NIS.

How can we help?

With RxPriceIndex™ we aim to help you make your business decisions clear by offering;

  • International pharmaceutical market overview
  • An intuitive user interface
  • Longitudinal data
  • Robust and transparent data
  • Price types including Ex-factory, wholesaler, pharmacy and retailer prices
  • Monthly updates and continuous analyst support.

The RxPriceIndex™ covers 31 EU markets along with USA and Japan with plans for further developments.  To request a customised report or a bespoke service, please get in touch with our team of expert analysts at sales@blackswan-analysis.co.uk.

Written by - Edward Capper, Healthcare Analyst, RxPriceIndex™ and Fabio De Cristofano, Sr Healthcare Analyst, RxPriceIndex™

Bibliography

Lindahl, A. K. The Norwegian Health Care System. Retrieved from The Commonwealth Fund: https://international.commonwealthfund.org/countries/norway/ - Accessed 01/04/2020

Ringard Å, S. A. (2017). The health system and policy monitor: regulation - Norway. WHO.

Sigrid Toft Fløystad, P. T. (2018). Global Legal Insights – Pricing & Reimbursement 2018, First Edition pp 144-153.

Weise, N. (2018). PPRI Pharma Profile Norway. WHO.