WZW criteria

What are the WZW criteria?

The WZW criteria are the yardstick against which every benefit of compulsory health insurance must be measured. The three letters are the German initials for effective, appropriate and cost-effective. Basic health insurance only pays for a treatment, a medicine, a laboratory analysis or an aid or appliance if all three conditions are met at the same time. You can think of the criteria as the three legs of a stool: if one is missing, the benefit does not stand.

The criteria apply to compulsory health insurance, in other words to basic health insurance under the Health Insurance Act (KVG). They determine what is included in the benefits covered by compulsory health insurance and what is not. Supplementary insurance under the Insurance Contract Act (ICA) has no such statutory limit; there, the contract decides.

What the three terms mean:

• Effective means that the benefit can achieve the intended medical goal. The law requires effectiveness to be proven by scientific methods.
• Appropriate means that the benefit is suitable for the specific illness and that its benefits outweigh its risks. An effective therapy can still be inappropriate in a particular situation.
• Cost-effective means that costs and benefits are in a reasonable relationship. If there are two equally good options, the cheaper one must be chosen.

How it works

The WZW check takes place at two levels. At system level, the Confederation decides which benefits belong to basic health insurance at all. For example, the FOPH maintains the List of Pharmaceutical Specialties, which contains all medicines covered by health insurance and their maximum prices. A medicine is only added to the list if it is authorised by Swissmedic and meets the WZW criteria. The FOPH checks cost-effectiveness using, among other things, a comparison with prices abroad and a therapeutic comparison with similar medicines. The conditions for listing are reviewed every three years.

Medical services by doctors are in principle covered by health insurance unless they are expressly excluded or restricted. The Confederation and the advisory commissions can review disputed benefits. Services not provided by doctors, such as physiotherapy or nutritional advice, are described exhaustively in the Health Care Benefits Ordinance (KLV), often with limits on quantity. For physiotherapy, for example, the insurer covers at most nine sessions per medical prescription.

At the individual level, your health insurer checks whether a specific bill corresponds to what was necessary for the purpose of the treatment. For expensive or lengthy treatments it involves its medical adviser. The medical adviser sees the medical records and gives the insurer a recommendation without passing on details of the diagnosis to the administration.

Legal basis

Art. 32 para. 1 KVG states that the benefits under Art. 25–31 KVG must be effective, appropriate and cost-effective, and that effectiveness must be proven by scientific methods. Under para. 2, the three criteria are reviewed periodically. Para. 3 and 4 require benefits for which there are indications that the criteria are not met to be evaluated in an evidence-based procedure and, if the result is negative, no longer reimbursed.

Art. 33 KVG empowers the Federal Council to designate benefits that are not covered or only covered under certain conditions, and to set up advisory commissions for this purpose. Art. 56 para. 1 KVG requires service providers to limit themselves to what is in the interest of the insured person and necessary for the purpose of the treatment; para. 2 allows reimbursement for benefits going beyond this to be refused. For medicines, Art. 65 ff. of the Health Insurance Ordinance (KVV) govern listing in the List of Pharmaceutical Specialties and the review every three years (Art. 65d KVV).

Example: physiotherapy for back pain

Lea, 41, has had recurring back pain for months, without any preceding accident. Her GP prescribes physiotherapy, which is covered by basic health insurance. The table shows how the WZW criteria shape the process.

What this means for you

You do not have to check the WZW criteria yourself, but they explain many of your insurer’s decisions. Three points help you in everyday life:

1. Ask for cost approval before expensive treatments. If it is unclear whether a benefit will be paid for, your doctor can have your insurer check in advance.
2. For medicines, look at the List of Pharmaceutical Specialties. As a rule, only products on the list are covered by health insurance. Cheaper generics often lower your retention fee.
3. Ask for a written decision if you are refused. Your insurer must tell you in writing, with reasons, why it is not paying. You can lodge an objection against it.

Because the benefits covered by basic health insurance are the same at every insurer, insurers mainly differ in basic health insurance through the premium. The premium calculator compares all offers for where you live. You can find key figures on the individual insurers under health insurers.

Common mistakes

• Confusing WZW with “as cheap as possible”. Cost-effective does not mean cheap, but a reasonable relationship between benefit and cost. An expensive therapy can be cost-effective if there is no equivalent alternative.
• Believing every medical prescription is automatically covered. Prescribed benefits must also be included in the benefits catalogue and stay within the limits on quantity.
• Mixing up supplementary and basic health insurance. The WZW criteria only apply under the KVG. What a supplementary insurance pays for is set out in its conditions.
• Simply accepting a refusal. Without a written decision you cannot challenge it. In a dispute, the Office of the health insurance ombudsperson helps free of charge.

We explain how we present benefits and costs under How we calculate.