PKV really pays for these medications and prescriptions

A close-up of a woman in a hospital gown holding a stethoscope.

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In Germany, more than 8.7 million people are privately insured; in Austria, the figure is around 3.3 million (they have taken out insurance through a private provider in addition to their regular health insurance). Especially in Germany, there is a common prejudice: If I am privately insured, my health insurance company will cover all costs for medications, prescriptions and treatments. But this is not entirely true, because there are significant differences depending on the tariff and insurance company.

The insurance contract determines the coverage of medications

When you take out private health insurance, many medications are covered, but not all. A look at the insurance conditions shows which costs are covered in detail. Reimbursement of costs is clearly regulated by the model conditions (MB/KK 2009, §4, Para. 2 and 3).

As for statutory health insurance also, medications are covered that are prescribed by physicians (including dentists) and can be obtained from pharmacies. Some tariffs also include coverage of alternative practitioner prescriptions. The private health insurance costs for this, however, can differ significantly from the standard tariffs and are more expensive due to the higher scope of benefits.

A close-up of a woman in a hospital gown holding a stethoscope.

/ voltamax

Insured persons should put their OKV through its paces, because not all medications and services are always covered.

Pay attention to the fine print

It is also interesting to take a look at the model conditions when it comes to the coverage of conventional medical services. For example, MB/KK 2009, § 4, para. 6 states the following:

The insurer will pay to the contractual extent for examination or treatment methods and medicines that are predominantly recognized by orthodox medicine. In addition, the insurer will pay for methods and medicines that have proven equally promising in practice or that are used because no conventional medical methods or medicines are available; however, the insurer may reduce its benefits to the amount that would have been incurred if conventional medical methods or medicines had been used.

If insured persons wish to have the costs of alternative treatment methods covered for a more successful healing process, this must usually be included in a supplementary tariff.

For those with statutory health insurance, the coverage of alternative cures such as For example, homeopathy soon be a thing of the past. The reason for this is an initiative of the KV Bremen, which recently decided to remove homeopathic services from the coverage catalog. The consequence: In the future legally insured ones would have to worry with an additional tariff module about the assumption of costs of their insurance.

Tariff refinements make the difference in cost coverage

Experience shows that the low-cost private health insurance tariffs work primarily with generic clauses. In practice, this means for insured persons: The costs for a drug are covered at 100%, for example, if it is a so-called copycat product that replicates the original active ingredient. Coverage of a non-generic drug (such as a Ibuprofen Genericon 600 mg forte film-coated tablets) is usually only covered on a pro rata basis, for example at 75%.

This is how the reimbursement of medications in private health insurance works

In contrast to statutory health insurance, insured persons with private insurance must first make advance payments. This means paying for the prescription or preparation at the pharmacy. In the further course, privately insured persons can have their costs reimbursed by submitting the receipts. The original prescription and the doctor's diagnosis are particularly important here. The latter is usually noted on the prescription or the medical invoice.

The diagnosis is therefore essential, as the private health insurance company checks whether the medication really had to be prescribed to alleviate the diagnosed ailment. Only then will the costs be covered.

If privately insured patients have been diagnosed with a chronic condition that requires permanent medication, experience has shown that a one-time presentation of the diagnosis is sufficient, as this is henceforth stored in the health insurance company's records and the assumption of costs for the medication is thus simplified.

Cost absorption without a doctor's visit - is that possible?

In Germany, there is a Medication is subject to compulsory prescription by pharmacies. Thus, there are some preparations that are only available with a prescription. In addition, preparations are sold in pharmacies that are not subject to prescription. Does private health insurance also cover these costs?

Once again, a look at the insurance conditions helps to answer this question. Preparations that are purchased without a prescription from a doctor are usually not covered by private health insurance. No preparations or treatments will be covered without a doctor's indication.

Common cold: Does private health insurance cover the costs?

For some years now, statutory health insurers have put certain preparations on their cross-off list for coverage. For example, doctors are no longer allowed to prescribe selected preparations for headaches or colds.

Private health insurers are much more accommodating on this issue. As soon as a doctor prescribes a preparation (even for colds), the costs are reimbursable, depending on the details of the tariff conditions.

Close-up of ceramic heart shape in red surrounded by tablets in beige color.

/ HeungSoon

Not all private health insurers have a heart for insured persons and the assumption of costs. For example, often only generic drugs are covered 100%.

Ordering medications on the Internet: What does private health insurance cover?

Online pharmacies are also becoming increasingly popular in Germany and Austria. Many insured persons take advantage of the opportunity to save costs and submit their prescriptions to the online pharmacy. Does private health insurance cover the costs for this as well?

As long as it is an officially licensed pharmacy, the costs for prescription preparations are also covered by private health insurance. In the meantime, there are even individual tariffs where savings incentives are created. If insured persons decide to use the often cheaper offers of online pharmacies, there is, for example, a higher reimbursement of the co-payment amounts.

Advance payment for medications: Do privately insured people always have to dip into their pockets first?

This is another persistent prejudice: privately insured persons must first pay all costs for their medications and treatments, and health insurance only pays later. In fact, the picture is different in practice. When private health insurance pays depends on the insurance tariff and its provisions.

It is possible, for example, to set up a customer account with the pharmacy you trust and agree on monthly invoicing with a payment deadline. In practice, this is mainly used for long-term medications. Anyone who receives an invoice from their pharmacy with a payment term of 14 days, for example, can submit it immediately to their health insurance provider. In most cases, private insurance providers respond quickly and transfer the amount covered. This is a relief for patients, because they do not have to pay in advance.

Author

Medikamio

Last Update

23.06.2022

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