Are Prescriptions Covered by Insurance?

The Spezialitätenliste (SL)

Swiss KVG insurance covers medications that are listed on the Spezialitätenliste (SL) — the official list of reimbursable drugs maintained by the Federal Office of Public Health (BAG). If a medication is on the SL, your insurer will cover it (subject to your Franchise and Selbstbehalt).

If a medication is not on the SL, KVG does not cover it. Your doctor may still prescribe it, but you pay the full cost yourself. You can check whether a specific medication is on the SL at spezialitaetenliste.ch.

How pharmacy billing works

There are two billing systems in Swiss pharmacies:

• Tiers payant — the pharmacy bills your insurer directly. You only pay your cost-sharing portion (Franchise and Selbstbehalt) later, when your insurer sends you a statement
• Tiers garant — you pay the pharmacy upfront, then submit the invoice to your insurer for reimbursement

Which system applies depends on your insurer and the pharmacy. Most large pharmacy chains use tiers payant. In either case, you need to present your insurance card (Versichertenkarte) at the pharmacy.

Franchise and Selbstbehalt apply

Prescription medications are subject to the same cost-sharing as any other KVG service. Your annual Franchise must be met first, and then you pay 10% Selbstbehalt (up to the annual maximum of CHF 700 for adults).

This means that early in the year — before your Franchise is used up — you may pay the full cost of your medications. Later in the year, once your Franchise and Selbstbehalt caps are reached, KVG covers 100%.

Generic substitution: 10% vs 20% Selbstbehalt

When a cheaper generic equivalent exists for your prescribed medication, the pharmacist may offer it to you. If you accept the generic, the standard 10% Selbstbehalt applies.

If you refuse the generic and insist on the brand-name (original) drug, your Selbstbehalt increases to 20% on that medication. This higher co-payment is an incentive to choose generics where available.

Your doctor can mark a prescription as "no substitution" (keine Substitution) if there is a medical reason to use the original. In that case, the standard 10% Selbstbehalt applies even for the brand-name drug.

Over-the-counter (OTC) medications

Medications available without a prescription (OTC) are generally not covered by KVG, even if they are on the SL. Some exceptions exist — for instance, certain OTC medications may be covered if prescribed by a doctor. Check with your pharmacist.

Special medications: Kostengutsprache

Some expensive or specialised medications require prior approval from your insurer before they will be covered. This is called Kostengutsprache (cost approval). Your doctor submits a request to your insurer, who decides whether to approve coverage.

This typically applies to:

• High-cost biologics and specialty drugs
• Medications used off-label (outside their approved indication)
• Medications with usage restrictions on the SL

Without Kostengutsprache, you may be liable for the full cost. Always ask your doctor whether prior approval is needed for expensive prescriptions.

Pharmacy markup

The prices on the SL include a regulated pharmacy markup. This markup covers the pharmacist's dispensing service and is part of the reimbursed cost. You do not negotiate drug prices — they are fixed by the BAG.