Medicines

What are medicines in health insurance?

In health insurance, medicines are above all about one question: who pays for them? The answer depends on whether a medicine is covered by health insurance. Covered means that basic health insurance pays the costs if it has been prescribed by a doctor and is on the List of Pharmaceutical Specialties (SL) of the Federal Office of Public Health (FOPH).

The List of Pharmaceutical Specialties comprises medicines that have been authorised by Swissmedic and that the FOPH has assessed for effectiveness, appropriateness and cost-effectiveness. For each medicine the list sets a maximum price, sometimes also a limitation, for example only for certain uses or a certain quantity.

There are also three other groups:

• Medicines without a prescription. You pay for over-the-counter products that you buy without a doctor’s prescription yourself, even if they are on the list.
• Medicines not on the list. Basic health insurance generally does not pay for authorised medicines that are not on the List of Pharmaceutical Specialties. Some supplementary insurance policies contribute.
• Use outside the authorisation. If a medicine is used for an illness for which it is not authorised or limited, the insurer only pays case by case after cost approval.

For medicines, the level of your retention fee also depends on the price. Under the rule that has applied in this form since 01.01.2024, if you choose an expensive product although there is a significantly cheaper alternative with the same active ingredient, you pay 40% instead of 10%. Cheaper alternatives are usually generics or biosimilars.

How it works

1. Prescription. Your doctor prescribes a medicine, on paper or electronically.
2. Dispensing. The pharmacy or the self-dispensing doctor’s practice dispenses the medicine. The pharmacy’s service when dispensing is also a benefit of basic health insurance.
3. Price. At most the price on the List of Pharmaceutical Specialties is billed.
4. Billing. The costs count towards your deductible. After that you pay a 10% retention fee, or 40% at the higher rate.
5. Information. Your doctor and the pharmacy must inform you if there is a generic for the prescribed original product or if a retention fee of more than 10% applies to the medicine dispensed.

The higher retention fee of 40% applies if the ex-factory price of a medicine is at least 10% above the average of the cheapest third of all medicines with the same composition of active ingredients. It applies to original products as well as to expensive generics. If the doctor demonstrably prescribes the original for medical reasons, or the pharmacy refuses a switch for medical reasons, the rate stays at 10%. The insurer only counts half of the part above 10% towards the CHF 700 maximum retention fee.

Legal basis

Art. 25 para. 2 let. b of the Federal Health Insurance Act (KVG) counts medicines prescribed by a doctor among the benefits of basic health insurance, and let. h the pharmacy’s service when dispensing. Under Art. 52 para. 1 let. b KVG, the FOPH draws up the List of Pharmaceutical Specialties with prices. Art. 52 para. 3 KVG states that medicines may be billed to basic health insurance at most at these prices.

The higher retention fee is governed by Art. 38a of the Health Care Benefits Ordinance (KLV): 40% of the costs exceeding the deductible if the ex-factory price exceeds the average of the cheapest third by at least 10% (para. 1); an exception for medical reasons (para. 7); the duty of the doctor and pharmacy to inform (para. 8). Under Art. 104a para. 2 of the Health Insurance Ordinance (KVV), the amount above the statutory retention fee only counts half towards the maximum under Art. 103 para. 2 KVV.

Case-by-case reimbursement is governed by Art. 71a–71d KVV: for medicines on the list used outside their authorisation or limitation (Art. 71a), for authorised medicines that are not on the list (Art. 71b) and for imported medicines not authorised in Switzerland (Art. 71c). Under Art. 71d KVV, special cost approval by the insurer after consulting its medical adviser is required; once the application is complete, the insurer decides within 2 weeks.

Example: original or generic

Sara, 47, needs a medicine for a chronic condition throughout 2026. She has already used up her CHF 300 deductible through doctor’s visits. There is the original product and a generic with the same active ingredient. The prices are assumed values; the rates follow from Art. 64 KVG and Art. 38a KLV.

What this means for you

• Ask about the generic. Ask at the pharmacy or your doctor whether there is a cheaper product with the same active ingredient. The List of Pharmaceutical Specialties shows prices and the retention fee.
• Get a prescription for long-term medicines. Basic health insurance only pays even for over-the-counter medicines on the list with a doctor’s prescription.
• Obtain cost approval beforehand. For expensive therapies outside the list, your doctor should apply for cost approval before treatment starts.
• Choose a suitable deductible. If you regularly need medicines, your costs are often above the deductible. A low deductible is then often cheaper. You can make the comparison with real premiums in the premium calculator and the deductible calculator.
• Check supplementary insurance. Some supplementary outpatient insurance policies partly cover medicines that are not covered by basic health insurance. The overview of health insurers takes you to the offers.

Common mistakes

• Buying without a prescription and submitting the bill. Without a doctor’s prescription, basic health insurance does not pay, even if the medicine is on the list.
• Overlooking the 40% retention fee. It is shown on the statement. Ask about an alternative before you collect your next pack.
• Not obtaining cost approval. Without cost approval, the insurer does not pay for medicines outside the list.
• Believing that all authorised medicines are covered. Authorisation by Swissmedic is only the precondition; what is paid for is what is on the List of Pharmaceutical Specialties.

We explain how we calculate our examples under How we calculate.