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Health insurance and cost approval: how it works
What basic and supplementary insurance cover, and what a cost-approval request involves.
Does health insurance pay for a treatment with medical cannabis? In most cases not automatically. This article explains the rules and what a cost-approval request involves.
Basic insurance
The Federal Office of Public Health (BAG) is clear: the list of benefits of mandatory health insurance currently contains no cannabis medicines. According to the BAG, the legal criteria of efficacy, appropriateness and cost-effectiveness have not been found to be met so far.
Reimbursement by basic insurance is therefore only possible in an individual case, under Articles 71a to 71d of the Health Insurance Ordinance (KVV). The BAG adds that it currently happens only in exceptional cases.
How a cost-approval request works
- The physician submits a request for cost approval (Kostengutsprache) to the health insurer.
- The insurer consults its medical examiner (Vertrauensarzt) before deciding (Art. 71d para. 1 KVV).
- Once the request is complete, the insurer decides within two weeks (Art. 71d para. 3 KVV).
- If it refuses, it has to give reasons to both the physician and the patient (Art. 71d para. 6 KVV).
The conditions are demanding. In short, the ordinance requires a large therapeutic benefit for a serious illness for which there is no effective authorised alternative. Whether that applies is decided by the insurer in each individual case.
Supplementary insurance
The BAG notes that, depending on the cover, a supplementary insurance may be obliged to pay. Ask your insurer which benefits your supplementary plan includes, and whether it needs a request in advance.
What it costs
According to the BAG, a treatment with cannabis medicines costs on average CHF 300 to 500 per month. The pharmacy states its prices before dispensing. Our consultation fees are separate and are set out on our prices page.
In our practice
Where medically indicated, our physician prepares the documentation for a cost-approval request. We cannot promise an outcome: the decision lies with the insurer.
This article is general information and not legal advice.
