The FOPH draws up various lists setting the prices and tariffs for medicines, which are refunded to the stipulated maximum under the compulsory health insurance or invalidity insurance (IV).
Specialities list (SL/LS)
The specialities list contains original formulations and lower-cost generics, including prices, covered by mandatory basic health insurance. A drug approved by swissmedic and contained in the SL must be effective, expedient and economical, and may have a limitation. Specialities list SL/LS
Medicines list with tariff
This is a list of products and active substances and excipients used in extemporaneous preparation, with the corresponding tariffs. These tariffs also cover the services provided by the pharmacist.
List of specialities for congenital anomalies (GG-SL)
The GG-SL contains medicinal products which are indicated exclusively for the treatment of congenital anomalies (birth defects) recognised by the disability insurance scheme (IV/AS) and whose use in the majority of cases begins before the age of 20 (Art. 3sexies of the Invalidity Insurance Ordinance). A medicinal product authorised by Swissmedic and listed on
the GG-SL must be effective, appropriate and economical, and may have a limitation. After a transitional period, the GG-SL will replace the existing list of drugs for birth defects and congenital disorders (GGML) as well as the list of medicinal products in the IV/IS circular on medical integration measures (KSME).
List of drugs for birth defects and congenital disorders (GGML)
This is a list of drugs to be paid for under mandatory basic health insurance that were covered for people receiving federal disability (IV/AS) benefits until age twenty that they will continue to require subsequently.
Compulsory health insurance covers the medicines which are prescribed by a physician, employed in accordance with the approved indications/uses specified in the package insert, and included on the list of reimbursable pharmaceutical specialities (Specialities List/SL).The reimbursement of SL products may be restricted to certain medical indications or specified quantities (so-called limitations, marked as “Limitatio L” in the SL).
In addition, the medicines prescribed by a physician which are compounded in a pharmacy are also reimbursed, if they are included on the list of active substances and other ingredients (List of medicines with tariff/LMT).
No, the costs of such medicines are not generally reimbursed.
By way of exception, the costs of such medicines are reimbursed in individual cases, provided the following conditions are met:
the use of the medicine is an indispensable precondition for another treatment measure that compulsory health insurance does reimburse and the focus is clearly on this measure, or
the medicine is expected to have a substantial beneficial effect against an illness that may be fatal or cause serious chronic harm to the health of the insured person, and for which a lack of therapeutic alternatives means that no other effective approved treatment is available.
Your health insurer will decide, after prior consultation with its independent medical advisory service, whether the conditions for such an exception are met and the costs of the medicine can be reimbursed.
The health insurer will, in consultation with the licence holder, decide on the amount to be reimbursed. It will assess whether the costs to be reimbursed are proportionate to the therapeutic benefit. The price that is reimbursed may not exceed the absolute maximum price specified on the SL.
Your doctor must inform you whenever he/she prescribes medicines for you outside the approved indications or limitations.
If compulsory health insurance does not cover the costs of such medicines, you may be able to claim reimbursement under a supplementary insurance plan.
As a rule, the costs of such medicines are not reimbursed under compulsory health insurance. Reimbursement is possible only in exceptional cases, under the same conditions and to the same extent as SL medicines used outside the approved indications or limitations (cf. no. 2 above).
Your doctor must inform you whenever he/she prescribes a medicine, which is not included on one of the lists.
If compulsory health insurance does not cover the costs of such medicines, you may be able to claim reimbursement under a supplementary insurance plan.
Such costs can be reimbursed only in exceptional cases if the medicine may be imported under the Therapeutic Products Act and the conditions for reimbursement of medicines used off-label or off-limitation are met (cf. no. 2). The medicine must be authorised for the indication in question by a
country with an authorisation system recognized as equivalent by Swissmedic.
The health insurer will reimburse the costs of importing the medicine. It will assess whether the costs to be reimbursed are proportionate to the therapeutic benefit.
Your doctor must inform you whenever he/she prescribes a medicine that is not included on one of the lists and is not authorized in Switzerland.
If compulsory health insurance does not cover the costs of such medicines, you may be able to claim reimbursement under a supplementary insurance plan.
