SGK updates drug reimbursement and transplant coverage rules

The Social Security Institution (SGK) has implemented comprehensive changes to its health reimbursement regulations, as published in the Official Gazette. These updates significantly alter how drugs, organ transplants, and specific medical procedures are financed.

Regarding pharmaceuticals, new definitions for “reimbursable unit price range,” “internal reference group,” and “drug market share” have been established. A critical new rule requires drugs that are the cheapest in their reference group to reach a 1% market share before being included in certain price calculations. Existing drugs failing to maintain this 1% threshold over a five-month period may be removed from these calculations.

In the field of transplantation, SGK will now cover the treatment costs for both recipients and donors during organ and tissue transplants. This includes travel and transfer expenses for moving patients or organs to licensed transplant centers. However, restrictions have been placed on ABO blood group incompatible kidney transplants; these will only be reimbursed for patients who cannot be treated via dialysis and can prove this through a third-level healthcare facility report.

Additionally, reimbursement criteria for certain cancer treatments, such as those for early-stage and metastatic breast cancer, have been updated to require reports from medical oncology boards. The regulations also include expanded coverage for bone marrow transplant packages and new reimbursement terms for specific rare neurological disease treatments.