Key points at a glance
- Basic health insurance only pays for medicines if they have been prescribed by a doctor (Art. 25 para. 2 let. b KVG).
- In addition, the medicine must be on the FOPH’s List of Pharmaceutical Specialties (Art. 52 para. 1 let. b KVG).
- Non-prescription medicines belong to dispensing categories D (after expert advice in a pharmacy or drugstore) and E (freely available), governed by Art. 43 and 44 VAM.
- Medicines you buy and pay for yourself without a prescription do not count towards the deductible or the retention fee.
- Some supplementary insurance policies contribute towards medicines not covered by basic insurance; the conditions are set out in the contract.
What is self-medication?
Self-medication means that you choose, buy and use a medicine without a doctor’s prescription. Typical examples are lozenges for a sore throat, a painkiller for a headache, a nasal spray for a cold or an ointment for minor skin irritation. You can get these products in pharmacies, in drugstores and partly in ordinary shops.
Which medicines you may buy without a prescription is decided not by the health insurer but by Swissmedic. The Swiss Agency for Therapeutic Products assigns every authorised medicine to a dispensing category. Two categories are relevant for self-medication: category D, dispensed after expert advice in a pharmacy or drugstore, and category E, freely available without advice.
For health insurance, the question is a different one: who pays? Basic health insurance only covers medicines if two conditions are met. The medicine must be prescribed by a doctor (or, in certain cases, by a chiropractor), and it must be on the FOPH’s List of Pharmaceutical Specialties. In self-medication there is no prescription, so you pay yourself.
Supplementary insurance can step in here. Supplementary outpatient insurance may include a contribution towards medicines that are not on the List of Pharmaceutical Specialties. Whether purchases without a prescription are included depends on the individual contract.
How it works
The dispensing categories determine where and how you can get a medicine:
| Category | Dispensing | Prescription needed? | Does basic insurance pay? |
|---|---|---|---|
| A | once, on a doctor’s prescription | yes | if on the List of Pharmaceutical Specialties |
| B | on a doctor’s prescription; in certain cases a pharmacy may dispense without one | yes, with exceptions | if prescribed and on the List of Pharmaceutical Specialties |
| D | after expert advice in a pharmacy or drugstore | no | only if nevertheless prescribed and on the List of Pharmaceutical Specialties |
| E | freely available | no | only if nevertheless prescribed and on the List of Pharmaceutical Specialties |
It follows that even a non-prescription medicine can be covered by basic insurance if a doctor prescribes it to you and it is on the List of Pharmaceutical Specialties. It then counts like any other benefit towards your deductible and the retention fee. If you buy the same product without a prescription, you pay for it yourself and the amount does not count towards the deductible.
A pharmacy may dispense certain prescription-only medicines in category B without a doctor’s prescription, for example for common illnesses with well-known active ingredients or to continue a long-term therapy. It must advise you in person and document the dispensing. Under Art. 25 para. 2 let. b KVG, basic health insurance pays for medicines prescribed by a doctor; without a prescription you usually pay yourself here too.
Legal basis
Art. 25 para. 2 let. b of the Federal Health Insurance Act (KVG) includes among the benefits of basic health insurance the medicines prescribed by a doctor or, under certain conditions, by a chiropractor. Art. 52 para. 1 let. b KVG requires the FOPH to keep a list of pharmaceutical specialties with prices, the List of Pharmaceutical Specialties. Only medicines on this list are covered in the outpatient sector.
Dispensing is governed by therapeutic products law. Art. 23 of the Therapeutic Products Act (TPA; in German HMG) divides medicines into categories with and without a prescription requirement, Art. 24 TPA governs the dispensing of prescription-only medicines and Art. 25 TPA the dispensing of non-prescription medicines, including by druggists with a federal diploma. The criteria are set out in the Medicinal Products Ordinance (VAM): Art. 43 VAM for category D, Art. 44 VAM for category E and Art. 45 VAM for the dispensing of category B medicines by pharmacists without a doctor’s prescription.
Example: a cold with and without a prescription
Luca, 28, has a deductible of CHF 2,500 and no costs so far this year. He has a cold. The amounts are assumptions; the rules are the statutory ones.
| Route | Costs (assumption) | Does basic insurance pay? | Luca pays |
|---|---|---|---|
| Lozenges and nasal spray from the drugstore | CHF 25 | no, no prescription | CHF 25, does not count towards the deductible |
| Advice and purchase in the pharmacy | CHF 25 | no, no prescription | CHF 25, does not count towards the deductible |
| Doctor’s visit with a prescription for the same products | CHF 120 consultation plus CHF 25 | yes, insofar as on the List of Pharmaceutical Specialties | CHF 145, counts towards the deductible |
Things are different if someone regularly needs a medicine that is on the List of Pharmaceutical Specialties, or if the deductible has already been reached for the year. Basic health insurance then covers prescribed medicines apart from the 10% retention fee.
What this means for you
For short, minor complaints, self-medication is usually the simpler and cheaper route. Get advice in the pharmacy or drugstore, especially if you take other medicines, are pregnant or if the symptoms last longer.
If you need a product regularly, it is worth asking for a prescription and a cheaper generic. If the product is on the List of Pharmaceutical Specialties, basic health insurance pays as soon as you have reached your deductible.
Your medicine costs are also a pointer when choosing your deductible: if you spend a lot on medicines covered by basic insurance, you are often better off with a lower deductible. Compare the premiums for both deductibles in the premium calculator. Whether your insurer offers supplementary insurance for medicines not covered by basic insurance is shown in its documents; you can find the profiles under health insurers.
Common mistakes
- Sending receipts to the insurer. Basic health insurance does not pay for purchases without a prescription and does not count them towards the deductible. Supplementary insurance may decide otherwise; read its contract.
- Believing non-prescription means never covered. Non-prescription medicines can also be covered by basic insurance if they are prescribed and on the List of Pharmaceutical Specialties.
- Treating complaints yourself for too long. Advice in a pharmacy or drugstore does not replace a medical check-up for persistent or severe symptoms.
- Overlooking interactions. Even freely available products can interact with other medicines. Say what else you take when you ask for advice.
Frequently asked questions
Does health insurance pay for non-prescription medicines?
Basic health insurance does not, if you buy them without a prescription. If a doctor prescribes you a non-prescription medicine and it is on the List of Pharmaceutical Specialties, basic health insurance pays for it after deducting the deductible and the retention fee.
Do pharmacy purchases without a prescription count towards the deductible?
No. Only costs for benefits that basic health insurance covers count towards the deductible. What you buy yourself without a prescription, you pay entirely yourself.
What is the difference between a pharmacy and a drugstore?
A drugstore sells medicines in categories D and E. A pharmacy also dispenses prescription medicines and may, in certain cases, dispense some of them without a doctor’s prescription, but must document this.
Is it worth seeing a doctor just to get a prescription?
Rarely. The consultation usually costs more than the medicine, and with a high deductible you pay for both yourself. It is different for medicines you need for a long time or regularly, or if you have already reached your deductible.
Related terms
- MedicinesBasic health insurance pays for medicines if a doctor prescribes them and they are on the FOPH’s List of Pharmaceutical Specialties, at most at the price set there. You pay the deductible and a 10% retention fee, or 40% for expensive original products with cheaper alternatives. You pay for medicines not on the list yourself or through supplementary insurance.
- List of Pharmaceutical Specialties (SL)The List of Pharmaceutical Specialties (SL, Spezialitätenliste) is the Federal Office of Public Health’s list of all medicines paid for by basic health insurance, together with their maximum prices. A medicine is only added if Swissmedic has authorised it and it is effective, appropriate and cost-effective. As a rule, basic health insurance does not pay for anything that is not on the SL.
- GenericsGenerics are copies of an original medicine with the same active ingredient, launched after the patent has expired. In basic health insurance, they are cheaper and protect you from the differentiated retention fee: if your medicine is significantly more expensive than the low-cost alternatives, you pay a 40% instead of a 10% retention fee.
- DeductibleThe deductible (Franchise) is the amount you pay yourself each calendar year in basic health insurance before your health insurer contributes to the costs. Adults have a deductible of at least CHF 300 and can choose up to CHF 2,500. A higher deductible lowers your premium but increases your share when you fall ill.
Sources
- Federal Health Insurance Act (KVG), Art. 25Art. 25 para. 2 let. b KVGfedlex.admin.ch
- Federal Health Insurance Act (KVG), Art. 52Art. 52 KVGfedlex.admin.ch
- Therapeutic Products Act (TPA), Art. 23–25Art. 23–25 TPAfedlex.admin.ch
- Medicinal Products Ordinance (VAM), Art. 40–45Art. 40–45 VAMfedlex.admin.ch
- FOPH: List of Pharmaceutical Specialties (SL)spezialitaetenliste.ch