List of Pharmaceutical Specialties (SL)

What is the List of Pharmaceutical Specialties?

The List of Pharmaceutical Specialties, SL for short (Spezialitätenliste), is the binding list of medicines paid for by compulsory basic health insurance. It is drawn up by the Federal Office of Public Health (FOPH) and updated continuously. For each medicine listed, it contains the maximum price per pack, the active ingredients, the pack sizes and any conditions for reimbursement. Doctors, pharmacies, hospitals and nursing homes may charge basic health insurance no more than these prices.

“Specialties” is an older technical term for industrially manufactured, ready-to-use medicines, as opposed to preparations made up in the pharmacy. The SL includes both originator products and the cheaper generics and biosimilars with the same active ingredient.

How it differs from other lists

The SL is one of several positive lists in basic health insurance. As a rule, anything that is not on the relevant list is not reimbursed.

• List of Pharmaceutical Specialties (SL): ready-to-use medicines with prices, kept by the FOPH.
• List of Medicines with Tariffs (ALT): products, active substances and excipients for preparations made up in the pharmacy, issued by the Federal Department of Home Affairs (FDHA).
• List of Analyses (AL): laboratory tests with tariffs.
• Aids and Appliances List (MiGeL): aids such as dressings, inhalers or blood glucose meters, with maximum reimbursement amounts.
• List of specialties for congenital disorders: medicines for treating congenital disorders that are reimbursed by invalidity insurance (IV); such medicines are not added to the SL.

The SL must also be distinguished from authorisation by Swissmedic. Swissmedic assesses whether a medicine is safe, effective and of good quality, and permits its sale in Switzerland. Whether basic health insurance then pays for it, and at what price, is decided by the FOPH through the SL. An authorised medicine is therefore not automatically covered by health insurance.

How it works

Admission

The manufacturer or authorisation holder applies to the FOPH for admission. A valid Swissmedic authorisation is a prerequisite. The FOPH then assesses the three criteria from the Federal Health Insurance Act (KVG): effectiveness, appropriateness and cost-effectiveness (WZW in German). To assess cost-effectiveness, it compares the price with the average in reference countries (foreign price comparison) and with the cost of other medicines for the same illness (therapeutic cross-comparison). An innovation premium may be added for new originator products. The FOPH consults the Federal Drugs Commission in the process.

Medicines advertised to the general public are not admitted. The FOPH can admit a medicine for a limited period while the WZW criteria are still being clarified, and can attach conditions.

Price

The price on the SL is a maximum price, known as the public price. It consists of the manufacturer’s ex-factory price, a distribution share for logistics, storage and dispensing, and VAT. For prescription-only medicines, the distribution share is made up of a price-related surcharge and a surcharge per pack; a uniform distribution share applies to medicines with the same active ingredient. Price increases require FOPH approval and are possible at the earliest two years after admission or the last increase. More on the pricing rules under medicine prices.

Review

Every three years, the FOPH reviews all medicines on the SL to check whether they still meet the admission conditions. For this purpose, the medicines are divided into three units by therapeutic group, and one unit is reviewed each year. If the price is too high, the FOPH orders a price reduction with effect from 1 December of the review year. Additional reviews take place when the patent expires and when the indications are extended.

Limitations

Some medicines are only covered under certain conditions. A limitation can relate to the quantity, the duration or the illnesses for which the medicine is reimbursed; often, cost approval from the health insurer is also needed. If a medicine is prescribed outside this limitation, the health insurer is in principle not obliged to pay for it.

Exceptions in individual cases

Within narrow limits, basic health insurance also pays for medicines outside the SL or outside a limitation. This is possible if the medicine is an essential prerequisite for another service covered by health insurance, or if a major therapeutic benefit is expected against an illness that may be fatal or cause severe and chronic impairment, and no authorised alternative is available. The health insurer decides on cost approval after consulting its medical adviser, within two weeks of receiving a complete application. It sets the reimbursement on the basis of the ex-factory price, with a price reduction of no more than 50% for uses with a major therapeutic benefit.

Legal basis

The SL is based on Art. 52 para. 1 let. b of the Federal Health Insurance Act (KVG): the FOPH draws up a list of pharmaceutical specialties and ready-made medicines with prices. Under Art. 52 para. 3 KVG, medicines may be charged to basic health insurance at no more than these prices. Under Art. 32 KVG, services must be effective, appropriate and cost-effective, and they are reviewed periodically.

The Health Insurance Ordinance (KVV) sets out the details in Art. 64 to 75:

• Art. 65 KVV: admission conditions (Swissmedic authorisation, no advertising to the public, WZW), limited duration and conditions.
• Art. 65a–65c KVV: assessment of effectiveness and cost-effectiveness with therapeutic cross-comparison, innovation premium and foreign price comparison, special rules for generics and biosimilars.
• Art. 65d KVV: review of all medicines every three years, price reduction with effect from 1 December.
• Art. 67 KVV: public price as the maximum price, consisting of the ex-factory price, the distribution share and VAT; price increases only with approval.
• Art. 71 KVV: publication of the SL and the basis for decisions by the FOPH.
• Art. 71a–71d KVV: reimbursement in individual cases with cost approval.
• Art. 73 KVV: limitations by quantity or indication.

The differentiated retention fee is governed by Art. 38a of the Health Care Benefits Ordinance (KLV): a 40% retention fee applies to medicines whose ex-factory price exceeds the average of the cheapest third of all medicines on the SL with the same active ingredient composition by at least 10%. This applies to originator products, generics, co-marketing medicines, reference products and biosimilars. It does not apply if the doctor, demonstrably for medical reasons, expressly prescribes the originator product or the pharmacist refuses a substitute for medical reasons (para. 7). Doctors and pharmacists must inform you if a generic is available and the retention fee is more than 10% (para. 8).

Example: originator or generic

Karin is 52, has already paid her deductible (Franchise) of CHF 300 this year and is prescribed a medicine for three months. The SL lists the originator product at CHF 90.00 per pack and a generic with the same active ingredient at CHF 45.00. The originator costs more than 10% above the average of the cheapest third. The prices are fictitious; the retention fees are set by law (Art. 38a KLV).

You can find the current price and retention fee for each medicine in the FOPH’s official search at spezialitaetenliste.ch. The SL is the same for all health insurers; a more expensive insurer does not pay for additional medicines. This is also reflected in the premium calculator: the differences between health insurers concern the premium, not the benefits.

What this means for you

1. Ask about the generic. If a generic is available, it often saves you retention fee. The pharmacy may replace an originator with a cheaper generic that is equally suitable medically, unless the doctor expressly requires the originator (Art. 52a KVG).
2. Check prescriptions. If the originator is needed for medical reasons, the doctor should give the reason on the prescription so that the 10% retention fee applies.
3. Wait for cost approval for expensive treatments. For medicines with a limitation or uses outside the SL, treatment should ideally only start once the health insurer has confirmed in writing.
4. Budget for medicines not covered by basic health insurance. You pay for over-the-counter medicines not listed on the SL yourself, or via supplementary outpatient insurance. You can see which health insurers offer which supplementary products under health insurers.
5. Adjust your deductible. If you need expensive medicines on a long-term basis, you are almost certain to reach your deductible. A low deductible is then usually cheaper; the deadline for changing it is 30 November, see deadlines.

Common mistakes

• Confusing Swissmedic authorisation with health insurance cover. An authorised medicine is not automatically on the SL.
• Overlooking the 40% retention fee. For originators with cheaper alternatives, you pay four times the retention fee if no medical reason is stated on the prescription.
• Ignoring limitations. A medicine on the SL may still not be reimbursed for your diagnosis if the limitation excludes it.
• Believing an expensive health insurer pays for more medicines. The SL applies equally to all health insurers.
• Submitting bills for over-the-counter medicines. Without an SL listing and a doctor’s prescription, basic health insurance does not pay; ask your supplementary insurer.