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CSS Insurance

Useful information about medication

Before any form of medication can be sold on the Swiss market, it is tested by Swissmedic – the Swiss agency for the authorisation and supervision of therapeutic products (medicinal products and medical devices). Swissmedic ensures that the authorised therapeutic product meets quality standards, and is effective and safe.

What medication does CSS Insurance pay for?

CSS pays the costs of medication under basic and supplementary insurance.

Basic insurance

When paying for medication that health insurers are required to cover, CSS refers to the regulations issued by the Federal Office of Public Health (FOPH). Medication on the Specialty List (SL) which has been prescribed by a doctor is paid for by mandatory basic insurance.

Supplementary insurance

Medication that is not covered under basic insurance but that has been approved by Swissmedic, the Swiss institute for therapeutic products, is covered by supplementary outpatient insurance. These medicines fall into the non-mandatory category, referred to as "Hors-liste (HL)" because they do not feature on the list of those that insurers are required by law to cover.

The insurance does not cover medicines that are on the list of pharmaceutical products for special application (LPPV) or on the list that supplements the LPPV (in German) . The supplementary LPPV list is not exhaustive and can be modified unilaterally by CSS at any time.

What medication appears on the Specialty List (SL)?

The Specialty List (SL) is a list of specialist pharmaceutical preparations which are covered by basic insurance. As a general rule, a doctor's prescription is required before they can be obtained.
The SL is published by the Federal Office of Public Health (FOPH) and reviewed every three years.

Original medication vs. generic form

An original medicine is a newly developed medicine that is the first with a specific active ingredient to be approved by Swissmedic, the Swiss drug authorisation authority. To cover the costs involved in development and research, original medicines are protected by patent for 15 years after being introduced onto the market. This patent must expire before it is possible to manufacture a generic form of the drug, which is identical with respect to its active ingredient, dosage and form of administration.

Co-payment under basic insurance

The cost of medically prescribed medication on the Specialty List is covered by mandatory healthcare insurance (basic insurance), less the appropriate co-payment.

When you send in an invoice, your co-payment share is deducted before it is reimbursed. It is made up of the annual deductible and the 10% retention fee (residual costs once the deductible has been taken away are capped at CHF 700 per year, or CHF 350 per year for children).

A 20% retention fee applies to medication (both original preparations and generics) if its price exceeds the average price of the cheapest one-third of all medicines with the same active ingredient by at least 10%. The higher retention fee will not be charged if an original preparation is crucial for medical reasons. In such situations, CSS requires a medical certificate from the attending doctor.