Reimbursement
Reimbursement rules for drugs approved by Swissmedic and accepted for reimbursement by BAG are regulated by the SL List.
Request for Cost Approval
For expensive therapies, it is essential to obtain a cost approval from the patient's health insurer before prescribing. The Swiss Society of Medical Officers and Insurance Doctors (SGV/SSMC) provides forms for a cost-coverage confirmation for drugs with need for a preliminary approval.
Off Label and Off Limitation Use
In the case of off-label treatments, a drug is, for example, dosed differently, administered in a different way or combination, or used for a different indication than approved in Switzerland. For cases not matching the official indication (off-label), the health insurance is allowed to ask a case-by-case evaluation and request the producing firm to contribute to the cost sharing. Art 71a-d of the KVV applies.
For cases outside of the official Limitatio fixed by BAG, health insurances apply the same rules as for Off-Label usage.
The SGV has developed an algorithm, which should be applied in the described cases od off-label and off-limitatio use od a drug.
