Covering my costs for medication

Most medications prescribed by a doctor are covered by basic insurance. However, some are only covered by supplemental insurance. Find out which medications are reimbursed under what conditions.

Reimbursement of costs for medications: Who pays what?

There are two systems for the reimbursement of medications:

The ‘Tiers Garant’ third-party guarantor system is the standard model under the Health Insurance Act (KVG): Policyholders initially pay for their medications at the pharmacy themselves. The costs are reimbursed by the health insurance provider as soon as the annual deductible is reached.
With the ‘Tiers Payant’ third-party payer system, policyholders do not have to pay for their medications at the pharmacy. The pharmacy sends the invoices directly to the health insurance provider. The policyholder then pays any co-payments.

Groupe Mutuel’s health insurance funds work under the ‘Tiers Payant’ third-party payer system.

Basic insurance covers medications that are included in the specialties list (LS/SL) and the list of medicines with tariff (ALT/LMT) and that have been prescribed by a doctor.

The specialties list is compiled and continuously updated by the Federal Office of Public Health (FOPH). It contains the medications approved by Swissmedic that are effective, appropriate, and cost-efficient.
The list of medicines with tariff shows the preparations, active ingredients and excipients used in the formulation.

Medication that is not covered by basic insurance

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The list of pharmaceutical products for special application (LPPA/LPPV) contains products that serve to increase general well-being, such as food supplements, cosmetics and dietary products. Products from the LPPA are not covered by compulsory health insurance. Supplemental insurances do not cover these items either.

One exception to this is our Optimum supplemental insurance: It reimburses sun cream that is on the list and purchased in a pharmacy.

Off-list medications: Covered by supplemental insurance

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Off-list medications are preparations that are authorized by Swissmedic for sale in Switzerland that are not listed in the SL or LPPA directories. These are only covered by supplemental insurance if they have been prescribed by a doctor.

Generics and biosimilars

Generics and biosimilars are copies of the original drugs: They are just as effective and reliable but are significantly cheaper.

Generics contain the same active ingredients as the originals but may differ in size and color.
Biosimilars are drugs that are produced from living organisms. These organisms are very similar to those used in the manufacture of the reference medicinal product.

Higher co-payment for original medicines

The Federal Council wants to reduce healthcare costs. It has therefore adopted measures to promote the purchase of generics:

Until 31 December 2023, you will pay a higher co-payment (cost share) if you decide to buy an original medication instead of a generic: 20% instead of 10%.
From 1 January 2024, if you buy the original of a medication instead of a generic or biosimilar (new) form, this co-payment will be 40%. It therefore makes sense to choose a generic or biosimilar whenever possible.

Even lower costs with PrimaFlex

With our PrimaFlex alternative basic insurance model, choosing generics is even more worthwhile. PrimaFlex is the first model in Switzerland to cover generics without a deductible. So if you buy a generic, you do not pay any deductible. And if your deductible has been reached for other reasons (e.g., visits to the doctor), you will not be penalized by the increase in the deductible.

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Our supplemental insurance

Not covered by basic insurance? Discover our supplemental insurance options that cover the costs of medications prescribed by your doctor.

Premium

Coverage at 90%, unlimited amount

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Global smart

Coverage at 90%, unlimited amount

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Supplemental health insurance with a bonus

Coverage at 90%, unlimited amount

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Supplemental care insurance

Coverage at 90%, amount limited to CHF 600 (level 1), to CHF 800 (level 2), unlimited from level 3.

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Optimum

Coverage at 90%, unlimited amount

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Ask for advice

Do you have any questions about our different supplemental insurance solutions? Our insurance advisers will be happy to answer any questions you may have about your insurance coverage.

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Frequently asked questions

Why has the co-insurance amount been increased for some medicines?

The increase in the proportion not reimbursed by health insurers (“co-insurance”) was decided by the Federal Council with the aim of encouraging people to purchase generic drugs and biosimilars and therefore make savings for compulsory health insurance (AOS/OKP).