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Old 07.06.2019, 18:46
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Dependent on medicine the insurance won't cover

Hi guys,
sorry for being a little subjective here.

I'm dependent on a medication and literally can't survive without it.

Many months ago I've noticed the insurer is charging me full price. I've talked to them and they requested hospital and family doctor documentation.

They've received it all and a few weeks later they paid me to me around 3000CHF back to my account.
Recently I've contacted them again, asking why they charge the full price again.

Their answer shocked me: "We rejected your request for the medication back then. You have to continue covering it at your own expense".
They refer me to a letter with their final negative response, they claim to have send by post, which I can't find and do not recall.

I just had to write this down, since it feels like a glitch in the matrix to me.
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Old 07.06.2019, 19:27
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Re: Dependent on medicine the insurance won't cover

https://www.ch.ch/en/ombudsman-service/

Good luck. I hope you get what you need.
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Old 07.06.2019, 19:40
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Re: Dependent on medicine the insurance won't cover

If these medicines are not on the official list of pharmaceutical specialties which can be found somewhere on the site of the Swiss Federal Office of Public Health. They indeed are not covered by the basic insurance.

Additional insurance is also not an option anymore since it is a pre-existing condition.

You can always ask your Doctor/Pharmacy if prescribed medicines are covered or not (to late now), you could see if it is possible to get other medicines which are on the list, or if buying them yourself in for example Germany is an option.
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Old 07.06.2019, 21:20
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Re: Dependent on medicine the insurance won't cover

Did your physician know that the medication was not covered? Is there an alternative that is covered?

I‘d speak to the physician again to see if he/she can advocate for you. Also check with the insurance....errors do happen. The insurer going back and forth suggests to me that some clarification is needed.

Finally, speak to the ombudsman. Their job is to work through these issues. Or maybe talk to them first - perhaps they can advise you about the best course of action.
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Old 07.06.2019, 21:37
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Re: Dependent on medicine the insurance won't cover

Quote:
Finally, speak to the ombudsman. Their job is to work through these issues. Or maybe talk to them first - perhaps they can advise you about the best course of action.
Maybe first have a look on the list, if these medicines are not on it than the ombudsman has no business with this issue.
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Old 07.06.2019, 21:53
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Re: Dependent on medicine the insurance won't cover

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Maybe first have a look on the list, if these medicines are not on it than the ombudsman has no business with this issue.
Actually it depends on the circumstances, certain drugs which are not on the list may be covered if the insurance company is given evidence from a doctor (or two) that no other medication is possible for the patient and this is the only alternative.
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Old 07.06.2019, 21:57
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Re: Dependent on medicine the insurance won't cover

Is this a recent/new medication you need? If so, I'm surprised the doctor didn't check with the insurance company that it would be covered even if it is on the approved list.
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Old 08.06.2019, 02:14
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Re: Dependent on medicine the insurance won't cover

Physicians are way too busy to check beforehand if a drug is covered or not.

oferet, you got good advice above. Now you need to do your homework, and fight for your rights.
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Old 08.06.2019, 07:22
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Re: Dependent on medicine the insurance won't cover

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Hi guys,
sorry for being a little subjective here.

I'm dependent on a medication and literally can't survive without it.

Many months ago I've noticed the insurer is charging me full price. I've talked to them and they requested hospital and family doctor documentation.

They've received it all and a few weeks later they paid me to me around 3000CHF back to my account.
Recently I've contacted them again, asking why they charge the full price again.

Their answer shocked me: "We rejected your request for the medication back then. You have to continue covering it at your own expense".
They refer me to a letter with their final negative response, they claim to have send by post, which I can't find and do not recall.

I just had to write this down, since it feels like a glitch in the matrix to me.
What's the name of the medicine?
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Old 08.06.2019, 08:56
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Re: Dependent on medicine the insurance won't cover

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Physicians are way too busy to check beforehand if a drug is covered or not.

oferet, you got good advice above. Now you need to do your homework, and fight for your rights.
Both my GP and my oncologist have checked whether or not an expensive medication is covered. Doctors are busy, but they should not be too busy to check - or have staff check if a proposed treatment plan is feasible.
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Old 08.06.2019, 10:06
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Re: Dependent on medicine the insurance won't cover

Can you help me to find this list on their website? (www.bag.admin.ch)
I've searched the German and English sections, and still couldn't locate it.
It's not under health insurance and not under medication.

Quote:
If these medicines are not on the official list of pharmaceutical specialties which can be found somewhere on the site of the Swiss Federal Office of Public Health. They indeed are not covered by the basic insurance.
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Old 08.06.2019, 10:10
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Re: Dependent on medicine the insurance won't cover

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Can you help me to find this list on their website? (www.bag.admin.ch)
I've searched the German and English sections, and still couldn't locate it.
It's not under health insurance and not under medication.
Try this?

http://bag.e-mediat.net/SL2007.Web.E...parations.aspx
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Old 08.06.2019, 11:07
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Re: Dependent on medicine the insurance won't cover

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Physicians are way too busy to check beforehand if a drug is covered or not.

oferet, you got good advice above. Now you need to do your homework, and fight for your rights.
Quote:
Both my GP and my oncologist have checked whether or not an expensive medication is covered. Doctors are busy, but they should not be too busy to check - or have staff check if a proposed treatment plan is feasible.
Agree with edot. My husband's diabetic doctor prescribed a new treatment for him which had only recently become available. Gave him a prescription for it, but told him not to take it to the pharmacy until he'd checked with husband's insurance company that they would cover it under his policy.
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Old 08.06.2019, 11:18
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Re: Dependent on medicine the insurance won't cover

Thanks! Yes, the medicine I need is in the list.

Nevertheless, despite it's an illness I got years after starting the insurance, despite being a standard medication, despite that doctors gave an opinion I truly need it, the insurer still decided not to cover it.

I have yet to find that document they claim to have sent me several years ago, where they explain why they reject the doctors' opinions

BTW I've asked them if they perhaps couldn't identify the medication because I was issued with a cheaper generic substitute and they replied that no, they recognize the medication alright and they know what prescribed medication it replaces, it's just that they insist not to cover the prescribed medication as well as any cheaper generic substitutes.
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Old 08.06.2019, 11:24
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Re: Dependent on medicine the insurance won't cover

You can also look up the drug here: https://compendium.ch

If it there is no Rückerstattungskat./Cat. de remboursement listed then it is not covered by basic health insurance. Also to be covered by basic health insurance the drug can normally not be used for off label treatments.
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Old 08.06.2019, 13:23
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Re: Dependent on medicine the insurance won't cover

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What's the name of the medicine?
Hi there!
I'm not such a conservative person. I just feel that starting to speak about my specific medical case is a little too much.

But really, there's nothing exciting or interesting down that lane mate... Not the illness, not the specific drug. They're both quite mainstream & boring and the medicine itself is not expensive at all... It's just annoying that the insurer won't cover it and ignore doctors' opinion.
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Old 08.06.2019, 13:48
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Re: Dependent on medicine the insurance won't cover

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Thanks! Yes, the medicine I need is in the list.

Nevertheless, despite it's an illness I got years after starting the insurance, despite being a standard medication, despite that doctors gave an opinion I truly need it, the insurer still decided not to cover it.

I have yet to find that document they claim to have sent me several years ago, where they explain why they reject the doctors' opinions

BTW I've asked them if they perhaps couldn't identify the medication because I was issued with a cheaper generic substitute and they replied that no, they recognize the medication alright and they know what prescribed medication it replaces, it's just that they insist not to cover the prescribed medication as well as any cheaper generic substitutes.

Also....things change. Five or six years ago, I was on a medication that was not covered in adults. Last year, I noticed that all of a sudden, it was covered with no intervention from me.

But really, your best course of action is to check with your doctor first, and possibly the ombudsman.
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Old 08.06.2019, 16:49
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Re: Dependent on medicine the insurance won't cover

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Hi there!
I'm not such a conservative person. I just feel that starting to speak about my specific medical case is a little too much.
Rats!
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Old 08.06.2019, 17:00
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Re: Dependent on medicine the insurance won't cover

You say it is not expensive so maybe it is an over-the-counter drug? Those are never covered even if you have a prescription for it.
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Old 08.06.2019, 17:07
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Re: Dependent on medicine the insurance won't cover

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You say it is not expensive so maybe it is an over-the-counter drug? Those are never covered even if you have a prescription for it.
That's not correct. Dafalgan is available OTC and also paid for under prescription.
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