The health insurance providers only reimburse the cost of a medicinal product as part of the statutory health insurance mandated by the Health Insurance Act (HIA) if it has been prescribed by a doctor and is on the List of pharmaceutical specialities (LS) managed by the Federal Office of Public Health (FOPH). Patients have to pay themselves for medicines not on the LS, or they are reimbursed through additional insurance that patients can take out voluntarily. Reimbursement in individual cases is regulated in Art. 71a-d of the HIO.
Only authorised medicinal products are included
The FOPH only includes medicinal products authorised by Swissmedic in its LS. They must also be effective, appropriate and cost-effective. The FOPH examines effectiveness on the basis of the documents that were decisive in Swissmedic’s decision to authorise the product. A medicinal product is considered to be cost-effective if it ensures the indicated, i.e. recognised by Swissmedic, curative effect with as little financial outlay as possible. The FOPH generally consults the Federal Medicines Commission (FMC) before it decides whether to include a medicinal product in the LS. In the outpatient setting (i.e. outside of hospitals) only medicinal products on the LS may be prescribed and dispensed at the expense of the statutory health insurance system. In hospitals, medicines that are not available in the outpatient setting (e.g. prepared within the hospital) may also be used and reimbursed by the statutory health insurance system.