Statutory points limit medication
Limitations on coverage of costs
Certain medications are only covered by basic insurance up to a defined maximum amount within a period of 90 days. The technical term is points limitation. Find out what it’s all about here.
After subtracting the deductible and the retention fee, basic insurance covers original medications or generics prescribed by a doctor that are on the Specialities List (SL) or on the List of Medicines with Tariff (ALT).
For certain medications or therapy groups – those medications with the same/similar indication – on the Specialities List, the Federal Office of Public Health has set a statutory points limit.
What does points limitation mean?
This refers to the maximum amount of a medication – measured in points (thus “points limit”) – that basic insurance may pay for a person within 90 days. Once this quantity has been reached, basic insurance will no longer cover this medication and all others in the same therapy group until the 90 days have elapsed.
As soon as a new 90 day period begins, the costs can be covered again in accordance with legal requirements.
Where can I find information on points limitation?
Information on the statutory points limit is included in the Specialities List. This applies to both individual medications and groups of therapies, such as sedatives, combined vitamin preparations, cardiovascular medications and products for sensitive skin.
The Federal Office of Public Health may amend the list at any time.
Points limitation – example
The drug Dexeryl, together with other medicinal products, belongs to the therapy group 10.10. “Products for sensitive skin”. The points limit for this group is 60 points, the drug Dexeryl itself has a point value of 10 points.
To calculate the points limitation, the points of all medications dispensed in therapy group 10.10 over a period of 90 days are added up. As soon as 60 points have been reached (for example, after six purchases of Dexeryl), the basic insurance will not cover any further costs for Dexeryl and all other medications in this therapy group during the ongoing period.
