Pricing and reimbursement
To what extent is the market price of a drug or medical device governed by law or regulation?
Medicines reimbursed by the basic health insurance are subject to price control by the State. The prices of non-reimbursed products are free and are not controlled by the government.
A ready-to-use medicine (whether it is delivered on prescription or not) must in principle appear on the list of specialties (LS) drawn up by the Federal Office of Public Health in order to be reimbursed by the basic health insurance. (unless it is covered by hospitals on a group package linked to the diagnosis). When deciding on the admission of a medicinal product to the LS, the Federal Office of Public Health sets its catalog price. This price is the maximum price that can be charged by healthcare providers and which will be reimbursed by mutual insurance companies. About 80 percent of sales of pharmaceutical products in Switzerland relate to products listed on the SL.
If a drug is not listed on the SL or is listed on the SL but is used outside the MA or outside the reimbursement limit, it must be covered by the basic health insurance funds if it does not exist. effective and authorized support. alternative treatment for a life-threatening or serious and chronic disease, and a high therapeutic benefit can be expected from its use, and in the situation of a “treatment complex” (i.e. when there is a link between medical services which are reimbursed and services which are not or only partially reimbursed when the non-reimbursed services are a necessary condition for the treatment, or are of considerable importance for the success of the treatment). In these situations, the mutuals determine the amount reimbursed and negotiate a contribution to the costs with the pharmaceutical company concerned.
For medical devices used or applied by the patients themselves or by persons assisting them in a non-professional capacity or by care providers providing nursing services, the health insurance funds pay a certain lump sum per device which appears in the list of means and equipment regardless of the price of the specific medical device in question. For medical devices implemented by medical health professionals or non-medical hospitals, reimbursement is governed by the tariff agreements regulating the reimbursement of their healthcare services.
Negotiations between manufacturers and suppliers
Should manufacturers of pharmaceuticals and medical devices negotiate the prices of their products with public healthcare providers?
For reimbursed drugs, the LS established by the Federal Office of Public Health indicates the maximum ex-factory price and the LS price. Health care providers can negotiate a lower price than the ex-factory price with pharmaceutical manufacturers. Sometimes discounts are granted, especially to hospitals. Prices for medical devices and non-reimbursed products may be negotiated between manufacturers and healthcare providers.
Under what circumstances does the national health insurance system reimburse the cost of medicines?
Under basic health insurance, health funds pay or reimburse ready-to-use drugs prescribed by doctors for outpatient care (or, in certain circumstances, chiropractors) who are listed on the SL s’ they are used in their indication. The SL list may come with limitations on reimbursement.
In two exceptional situations, the cost of a product which either is not listed on the SL, or is listed on the SL but used outside the MA or outside the reimbursement limit, is covered by the basic health insurance: in a situation where there is no effective and authorized treatment alternative for a fatal or serious and chronic disease and a high therapeutic benefit can be expected from its use, and in the situation of a “therapeutic complex” (c i.e. when there is a very close link between reimbursed services and non-reimbursed or partially reimbursed services when the non-reimbursed services are a necessary condition for the treatment or are of considerable importance for the success of the treatment). In both situations, the trusted physician of the relevant health insurance fund should be consulted, and the health insurance fund should approve reimbursement in advance and determine the extent of reimbursement after negotiating a co-payment. with the manufacturer.
In the hospital sector, drug costs are mostly paid for and included in lump sum payments per case. For certain medicines, separate additional costs may be charged by the hospital to the health insurance funds.
An optional complementary private insurance can also cover certain authorized medicines which are not listed in the SL.
Awarding of prices
If applicable, which body is competent for decisions concerning the pricing and reimbursement of drugs?
The competent authority is the Federal Office of Public Health. It decides on the admission of finished drugs to the LS. A drug is only admitted to the LS if the applicant can demonstrate its effectiveness, usefulness and economy. The relevant criteria for setting the LS price of an original product are the prices of medicines in Switzerland with the same indication or a similar mode of action and the average price of the product in other countries. Currently, prices from nine reference countries – Germany, Denmark, England, the Netherlands, France, Austria, Belgium, Finland and Sweden – are used for this comparison. To determine the SL price, the Federal Office of Public Health adds a distribution margin to the ex-factory price determined according to the two criteria described above. Compliance with SL admission requirements is, in principle, reviewed every three years. A review of the conditions for admission to the SL also takes place immediately after expiry of patent protection, as well as in the following situations: authorization of a new indication by Swissmedic, restriction of an indication by Swissmedic, request for modification of a limitation and request for a price increase. The SL prices of generics are determined according to the prices of their reference products. Currently, a review of some of the drug pricing provisions is underway, including changes to reference countries and review of patent protection.
Are drug manufacturers or distributors legally obliged to grant a discount to health insurance funds or third parties?
There is no legal rule obliging drug manufacturers or distributors to grant certain discounts. The care providers must pass on to the debtor of the care product or service (insurance or patient) the discounts they have received on the drugs or on the services reimbursed by the basic health insurance.
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