Processes

Outpatient care

Billing CSS Insurance correctly: this information sheet shows you the administrative process for checking outpatient care services.

Specialty List

For medicines to be included in the Specialty List, they must meet certain eligibility criteria, i.e. they must be effective, appropriate and cost-effective.

Specialty List for a limited period

The Federal Office of Public Health (FOPH) can include a medicine in the SL for a limited period (Art. 33 para. 3 KVG).

This may happen, for example, if it is not yet possible for the FOPH to reach a definitive conclusion about satisfaction of the eligibility criteria when assessing a medicine for inclusion in the list. In particular, a medicine will be given a temporary listing if initial findings show that it promises to benefit patients, but further study results or price reviews are required for a sound assessment.

Commitment to provide cover for temporarily listed medicines

If you request a commitment to provide cover for a medicine that is temporarily included in the SL, we can only issue a commitment that provides cover up to the date on which the temporary listing period expires.

If the limitation remains in effect at the end of the period of temporary inclusion in the SL, our commitment to provide cover will automatically be extended (up to the next temporary limitation date, if any). You don't have to do anything.

If the FOPH revises the listing, you will need to request a new commitment to provide cover.

Your questions answered

Why is the commitment to provide cover only valid for such a short period?

If a medicine is included in the Specialty List for a limited period only, our commitment to provide cover cannot extend beyond that date. The commitment to provide cover cannot be for longer than the period of inclusion in the list.

The commitment to provide cover has ended. Does a new report have to be submitted?

If the limitation remains in effect at the end of the period of temporary inclusion in the SL, our commitment to provide cover will automatically be extended (up to the next temporary limitation date, if any). You don't have to do anything.

You only need to submit a new request if the FOPH revises the medicine’s listing.

Will the cost still be covered if a client obtains the medicine from their doctor or pharmacy at the end of the temporary limitation period?

Yes, if there is no change to the limitation.

No, if the limitation has changed. In that case, you will need a new commitment to provide cover.