Information for hospitals & clinics (medication reimbursement)

The Federal Health Insurance Act (KVG) sets out which benefits from the compulsory health insurance (OKP) can be reimbursed. The obligation to pay remuneration only extends to those medications that are on the specialities list (SL). There is no general obligation to pay remuneration from the OKP for medications that are not on the SL.

The KVG lays down the benefits from the OKP for which remuneration will be paid out. Art. 71a-d KVV allows for an exceptional remuneration in individual cases for medications or indications that are not on the SL. Remuneration in accordance with Art. 71a-d KVV, however, is only possible if the following criteria are met:

• The illness may be fatal or result in severe or chronic health impairments for the insured person.
• Greater therapeutic benefit is to be expected.
• There are no other effective treatment methods available which are on the SL.
• If the use of a specific medication constitutes a vital prerequisite for the implementation of another statutory benefit covered by the OKP, which clearly takes priority (treatment complexities).

The Helsana Group – in consultation with the medical examiner– is responsible for evaluating the assumption of costs for such individual cases. We require detailed information to allow us to evaluate individual cases promptly. Please complete in full the cost approval form from the Schweizerische Gesellschaft der Vertrauens- und Versicherungsärzte (Swiss Society of Medical Examiners and Occupational Health Doctors) which has been specially created for applications in accordance with Art. 71 a-d KVV. This will prevent any potential queries from being made which could result in delays to the final evaluation.