Simplified “family doctor” models

It’s an alternative model to the standard basic health insurance model. You receive the same benefits as with a standard basic health insurance model but pay a lower premium. In return, you agree to first see the family doctor you have chosen.

Your family doctor, also known as “general practitioner (GP)”, examines you and refers you to a specialist if necessary. This avoids unnecessary consultations and helps to reduce health care costs.

If your family doctor or another doctor refers you to a specialist, you must ask your GP to draw up a short certificate, i.e. a "referral voucher". Some doctors send it to us electronically. If this is not the case, you can ask your doctor for the referral voucher (a simple signed note is sufficient, mentioning the specialist recommended and the period of validity of the certificate). You can send it to us by post or via your online customer area.

You are not required to consult your general practitioner beforehand in certain specific cases (e.g. for consultations with a gynaecologist, eye specialist, etc.).
You will find all the necessary information in your special terms and conditions of insurance.

This model is an alternative to the standard model of basic insurance. You will receive the same benefits as under the standard model of basic health insurance but will pay a lower premium. In exchange, in the event of a health problem, you undertake to choose a prior approach that suits you best according to your situation:

• contact our telemedicine partner on 0800 852 852 for an advice session
• visit one of our partner pharmacies for an advice session
• consult your family doctor directly if you wish, provided you have given us the doctor’s details beforehand.

If you choose to receive advice from our telemedicine partner or in a pharmacy, you will now be free to decide, after having received the advice, on the next steps of your medical treatment during the time window defined by the telemedicine partner or partner pharmacy.

And if you choose to consult your family doctor directly and he refers you to a specialist, you must ask the doctor to issue a brief certificate, also called a "referral voucher" (a simple signed note is sufficient, mentioning the type of specialist recommended and the period of validity of the certificate). You can then send it to us by post or via your online Customer Area (if you prefer, you can also ask your doctor if he agrees to send it directly to us).

We improved these basic health insurance models to better meet the expectations of our insured persons and meet their needs:

• Flexible rules that focus on the added value of the model, rather than on its constraints.

Discussions and focus groups with our customers helped us to define the features of PrimaFlex (e.g. free choice of the first point of contact in any situation or freedom of action following the consultation). Therefore, PrimaFlex is a model designed by insured persons for insured persons. Moreover, we are sure that we will not need to oblige our policyholders to follow the rules of the model, as they will see the significant added value and savings potential offered by the first points of contact (telemedicine and partner pharmacies) as well as the various benefits exclusive to PrimaFlex.

• We care about meeting our policyholders’ expectations

We want to spare our policyholders unnecessary administrative procedures and soften certain rules that are too strict and lead to discontent (e.g. we will no longer refuse reimbursements if a policyholder does not comply with the rules of the model).

Yes, you are exempted from contacting one of the above-mentioned first points of contact in certain special cases (e.g. in case of emergency or for consultations with a gynaecologist, ophthalmologist, etc.). The list of special cases can be found in your special terms and conditions of insurance.

The basic health insurance models concerned by the improvement, as well as their related benefits, will not change:

• The operating rules of your previous model have not changed but have been simplified and improved. Next year, you will be able to continue to follow the rules of your old model, which have been included in your new "PrimaFlex" model, but you will also be able to choose other options for prior medical advice if you wish. This will give you more flexibility as well as exclusive benefits.
• Compared to the standard model, you will continue to benefit from the same attractive conditions (premium reduction) as now. Like every year, the exact amount of the 2023 premiums may vary, depending on health cost trends. Your insurance certificate, which you will receive by mail in October, will indicate your 2023 premium. (Premiums for the following year cannot be notified until the Swiss Federal Council officially announces them in September.)
• The medical benefits covered by your insurance will remain the same. The benefits of basic health insurance are defined by the Law on Health Insurance (LAMal/KVG) and are therefore identical, regardless of the insurance company and your basic health insurance model.
• If your canton of residence pays part of your health insurance premium, the subsidies to which you are entitled will not be affected by this change.
• Your deductible amount will remain the same next year. If you wish to change your deductible, you must notify us by 30 November 2022 for a reduction or by 30 December 2022 for an increase (deadlines for the insurer to receive your request).
• Health data shared with our telemedicine partner and partner pharmacies will remain the same as currently. Their secure processing is necessary for the proper functioning of your model, in compliance with the Federal Law on Data Protection (LPD/DSG).
• If you were insured under the PrimaTel model, your family doctor will remain the same next year. If you were insured under the CallDoc and PrimaPharma models, you may provide us with the name of a family doctor if you wish to be free to consult him or her under PrimaFlex. Your family doctor does not need to be on a specific list and if you decide to change your family doctor, you can simply inform us before your first appointment as preferred:
  - contact form
  - letter
  - telephone
  - online customer area
• Your supplemental insurance policies will not be affected by this upgrade, which only concerns basic health insurance.

The terms and conditions of insurance have been reviewed to make them more straightforward and user-friendly. These changes will apply from 2023:

• You will have more flexibility in the event of a health problem, as you will now be able to choose the most appropriate option depending on your situation:
  • Contact our telemedicine partner on 0800 852 852 for an advice session
  • Visit one of our partner pharmacies for an advice session
  • Consult your family doctor directly if you wish, provided you have given us his or her contact details beforehand.
• You will benefit from exclusive services. To help contain rising health costs, "PrimaFlex" is the only model in Switzerland that does not charge the deductible for some benefits (e.g. generic drugs) and that actively promotes prevention through its partners (e.g. tests offered free of charge in a pharmacy when the pharmacist deems it necessary or breast cancer screening without a deductible recommended by our telemedicine partner, based on certain criteria, but irrespective of your age or place of residence).
• We will no longer refuse reimbursements when an insured person does not comply with the rules of their basic insurance model. However, insured persons will receive a letter reminding them of the rules. In case of repeated non-compliance, insured persons will be automatically transferred to the standard model with free choice of doctor.