Reimbursement for the cost of medicinal products in individual cases

Provided certain conditions are met, compulsory health insurance may reimburse the cost for medicinal products in individual cases even if they are not included in the list of pharmaceutical specialties (LS).

Statutory foundation

According to articles 71a–71d of the Ordinance of 27 June 1995 on Health Insurance (HIO), basic insurance reimburses the cost for medicinal products in individual cases,

if they are included in the LS but were dispensed outside the specialist information approved by Swissmedic or the LS limitation;
if they are not included in the LS but have been approved by Swissmedic;
if they are not approved by Swissmedic but are imported from a country with an authorisation system considered by Swissmedic to be equivalent and which has approved the products in question for the corresponding indication.

Conditions

In order for the cost of a medicinal product to be reimbursed in an individual case, one of the following criteria must be met:

If use of a medicinal product represents an indispensable precondition for the provision of another, essential treatment that is covered by compulsory health insurance, and if such treatment is clearly paramount, compulsory health insurance will also cover the medicinal product even though it is not included in the LS (a so-called treatment complex).
If it’s not a treatment complex, compulsory health insurance expects the use of the medicinal product (and the reimbursement of its cost by the compulsory health insurance) to result in a significant treatment benefit against an illness that may be fatal for the insured person or entail severe and chronic health impairment. Furthermore, there is no other effective and authorised treatment option available that is included in the LS.

Compulsory health insurance reimburses the cost of a medicinal product in individual cases only upon specific recommendation by the insurance provider after consultation with the medical examiner. The insurance provider agrees with the Swiss authorisation holder of the medicinal product on the amount to be reimbursed and verifies that the cost covered by the compulsory health insurance is proportionate to the therapeutic benefit.

Cost reimbursement form

The treating physician must submit the application for cost reimbursement to the insurance provider before the start of treatment. The Swiss Society of Medical Examiners makes standardised cost reimbursement forms available on its website for the purpose of assessing applications regarding the reimbursement of costs for medicinal products in individual cases. These forms ensure consistent implementation of the regulations. The cost reimbursement forms can be accessed via the link below.