Reimbursements for medicine expenses
Starting 1 January 2016, reimbursements for prescription medicines under the Health Insurance Act will be available only after meeting an initial deductible of €50 per calendar year.
You can be reimbursed for the cost of medicines that a doctor has prescribed to you for the treatment of an illness. The reimbursement is deducted from the price of the medicine you are purchasing.
Purchases of prescription medicines covered by the reimbursement scheme count towards the deductible.
The reimbursement only covers necessary medicine expenses. To qualify for a reimbursement, you must take the medicine as instructed and purchase it for 3 months' use at a time in the most economical package size.
Further, the medicine, emollient cream or clinical nutrient you are purchasing must have been confirmed as reimbursable and as having a reasonable wholesale price by the Pharmaceuticals Pricing Board, which operates in affiliation with the Ministry of Social Affairs and Health. A particular medicine can only be confirmed as reimbursable with respect to specific medical indications noted in the summary of product characteristics. If such confirmation has not been given, you will have to pay full price.
Emollient creams prescribed to you by a doctor for use in the treatment of a chronic skin condition are reimbursed at the basic reimbursement rate. Medicines whose purpose is to prevent illness or maintain good health are not reimbursable. The pharmacy may suggest that a medicine prescribed to you be exchanged for a more affordable alternative, unless this is expressly forbidden by your doctor or yourself. More information about the prices and reimbursements is available at the Medicinal Products Database.
Reference price system
Certain medicines belong to a reference price system, which comprises several reference price groups. Each group consists of interchangeable medicines (medicines that can be substituted for one another). Each of the medicines in a reference price group carries the same price regardless of its market price.
Pharmaceutical companies provide quarterly price notifications to the Pharmaceuticals Pricing board, which confirms the reference price group and reference price of each medicine. The reference price is calculated on the basis of the least expensive alternative in the reference price group as follows:
- If the price of the least expensive medicine in a reference price group is less than EUR 40, the reference price is this price plus EUR 1.50.
- If the price of the least expensive price in a reference price group exceeds EUR 40, the reference price is this price plus EUR 2.00.
If a particular medicine belongs to a reference price group and its price exceeds the reference price, the reimbursement is calculated on the basis of the reference price. This means that you would pay the copayment and the difference between the market price and the reference price. The difference does not count towards your annual limit for out-of-pocket medicine expenses. If the market price is the same or lower than the reference price, the reimbursement is calculated on the basis of the actual price. If your doctor disallows generic substitution, Kela will pay the reimbursement on the basis of the actual price even if the medicine belongs to a reference price group.
For more information about the prices of medicines, reimbursement criteria and interchangeable medicinal products, see Medicinal Products Database.
Information for marketing authorization holders of medicinal products
- Pharmaceuticals Pricing Board: Reference price system
There are three rates of reimbursement:
- Basic reimbursement (40 % of the price)
- Lower special reimbursement (65% of the price)
- Higher special reimbursement (100% of the price; a EUR 4.50 copayment is charged for each medicine purchased at one time).
With certain medicines, the availability of basic reimbursements is limited. In order to be reimbursed for these medicines, you must submit Medical Certificate B to Kela.
If your out-of-pocket medicine expenses in a calendar year exceed the treshold of EUR 610.37, the exceeding part is reimbursed in full. A EUR 2.50 copayment applies to each purchase made after you have reached the entitlement treshold.
By presenting your Kela card, the reimbursement can often be credited to you directly at the pharmacy. If the reimbursement is not credited directly, you can claim it from Kela within 6 months of the purchase with the form SV 178e (in English). Remember to enclose to the application all the required documents.
Last modified 14/04/2016