Cost sharing for prescription medicines

Kela provides reimbursement for part of the cost of medicines, emollient creams and clinical nutrients that are covered by the reimbursement system. You pay some of the cost yourself in the form of a copayment or deductible.

Initial deductible

You can get a reimbursement for your medicine expenses once you meet the initial deductible. The initial deductible is assessed on a calendar year basis. As of 2017, it stands at €50.

Children and adolescents are exempt from the initial deductible. It is applied from the beginning of the year in which you reach the age of 19 years.

Any medicines, emollient creams or clinical nutrients you purchase on prescription count towards the initial deductible. Depending on the price of the products, it may take one or several purchases before you meet the initial deductible. The part of the price that exceeds the reference price does not count towards the initial deductible.

If the products you purchase do not belong to the reimbursement system, the costs do not count towards the initial deductible.

Kela and the pharmacy have up-to-date information about your progress towards meeting the initial deductible. Once you meet the deductible, you will get the reimbursement due to you at the pharmacy.

The initial deductible counts towards your annual maximum on out-of-pocket costs.

You can check your initial deductible and annual out-of-pocket maximum status by logging into Kela's online custome service (available in Finnish and Swedish) and selecting Sairaanhoitokorvaukset > Lääkkeiden omavastuukertymä.

Example: Customer's first purchase of medicines does not meet the initial deductible limit (€50)

A customer buys prescription medicines covered by the reimbursement system at a total cost of €40.

  • €40 is applied towards the customer's initial deductible.
  • The customer does not yet get a reimbursement for the medicines she purchased.
  • She pays €40.

She gets a reimbursement once she meets the initial deductible when purchasing further prescription medicines in the same calendar year.

Example: Customer's first purchase of medicines meets the initial deductible limit (€50)

A customer buys prescription medicines covered by the reimbursement system at a total cost of €80.

  • She meets the €50 initial deductible,
  • and gets a reimbursement for the part of the price exceeding the initial deductible.
  • She pays the initial deductible of €50. On the price exceeding €50, she pays a copayment specific to each reimbursement category.

She gets a reimbursement for all her further medicine purchases in the same calendar year and will not be charged the initial deductible.

Example: Customer meets the initial deductible (€50) when she buys medicines from several reimbursement categories at the same time (special reimbursement rates of 65% and 100% and basic rate of 40%)

If a customer purchases medicines from several reimbursement categories, the purchases are handled as follows for the purpose of reimbursement:

  • The price for the medicines at the basic rate of reimbursement is €25. The entire amount counts towards the initial deductible.
  • The medicines in the lower special rate of reimbursement cost €20. This sum, too, counts towards the initial deductible. The total amount applied towards the deductible is now €45.
  • The medicines in the higher special rate of reimbursement cost €15. €5 of this sum counts towards the initial deductible, which means the customer meets the €50 initial deductible. She gets a reimbursement at the rate of 100% for the first €10 in excess of the initial deductible, and pays a medicine-specific copayment of €4.50.
  • The total cost of the medicines purchased at this time is €54.40.

She gets a reimbursement for all her further medicine purchases in the same calendar year and will not be charged the initial deductible.

Copayment after meeting the initial deductible

Once you meet the initial deductible, you are reimbursed for your medicine purchases. The pharmacy deducts the reimbursement from the price of the medicine, and you pay the rest. If the medicine is included in the reference price system, you will not be reimbursed for the part of the price that exceeds the reference price.

The amount you pay out of pocket depends on the reimbursement category of the medicine and any special reimbursement entitlements granted to you.

Reimbursement category Reimbursement Copayment
Reimbursement categories
Basic rate of reimbursement 40% 60%
Lower special rate of reimbursement 65% 35%
Higher special rate of reimbursement 100% €4.50/medicine/purchase

Annual maximum limit on out-of-pocket costs

The part of the price of reimbursable prescription products that you pay yourself counts towards your annual maximum limit on out-of-pocket costs. The initial deductible also counts towards the annual out-of-pocket maximum. However, should the price of the medicine exceed the reference price, the exceeding part does not count towards the annual maximum.

In 2016, the limit is set at €610.37. If you reach the annual maximum, you become entitled to an additional reimbursement for your medicine costs. That means that you only pay a €2.50 copayment for your medicines for the rest of the year.

You can check your progress towards reaching the annual out-of-pocket maximum by going to Kela's online customer service (available in Finnish and Swedish) and selecting Sairaanhoitokorvaukset > Lääkkeiden omavastuukertymä.

Exceptional copayment applicable to the higher special rate of reimbursement and the additional reimbursement

You are reimbursed for your medicine costs if you buy medication for three months' use at a time. However, in certain situations you will not be able to buy the full amount at the same time. This applies for example to:

  • dose-dispensed medicines
  • clozapines, peritoneal dialysis solutions and medical oxygen
  • medicines dispensed in several instalments because of efficacy or other pharmaceutical issues.

If you are entitled to reimbursement at the higher special rate or to an additional reimbursement, you will pay a copayment (as shown in the table below) for the types of products listed above at the beginning of each week of treatment. An exceptional medicine-specific copayment is charged for at least one week of treatment.

Reimbursement category Reimbursement Copayment
Exceptional copayment rate for specific medicines
Higher special rate of reimbursement 100% Medicine-specific reimbursement: €0.38 per each new week of treatment
Additional reimbursement 100% Medicine-specific reimbursement: €0.21 per each new week of treatment

 

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