Medication costs – insurance cover and co-payments

Doctors normally use prescriptions to prescribe drugs for a patient. The prescription contains details such as the active ingredient and the dose to be taken by the patient. If the drug is only available on prescription from the pharmacy, it is known as a prescription drug. The requirement for a doctor to issue a prescription ensures that patients only take the drug in accordance with the doctor’s instructions.

Over-the-counter medication can be purchased in pharmacies without a prescription. Examples include certain low-dose pain medication and medicated ointments.

Prescriptions for medication can have different colors. The different colors are used to indicate different prescription types, such as a prescription covered by private health insurance or one covered by statutory health insurance. Different colors also indicate different validity periods and the costs to patients themselves:

• Pink prescription covered by statutory health insurance: With these prescriptions, the cost of the drug is normally covered by statutory health insurance funds, with the exception of the statutory co-payment, which is to be paid by patients themselves. Pink prescriptions are valid for a period of 28 days from the day they are issued. They are increasingly being replaced by the electronic prescription (e-prescription) for prescription drugs.
• Blue prescriptions covered by private health insurance: With these prescriptions, patients with private health insurance must pay for the prescription drugs themselves. Individuals with statutory health insurance are issued with blue prescriptions for drugs that are not included in the catalog of benefits offered by statutory health insurance providers. Blue prescriptions are valid for three months.
• Green prescriptions: These contain recommendations for over-the-counter medication. The costs of these medications are not normally covered by statutory health insurance. The recommendation remains valid for an unlimited period of time.
• Yellow prescriptions: Yellow forms are used for drugs that fall under the guidelines governing controlled substances. These are valid for seven days.
• White “T-prescriptions”: These are special prescriptions for drugs containing teratogenic substances, i.e., substances that can cause damage to the unborn baby if taken during pregnancy. These prescriptions are numbered and the pharmacy always keeps a carbon copy. They are valid for six days and can only be issued by doctors with relevant expertise and following consultation with the patient.

Statutory health insurance funds usually cover most of the costs of prescription drugs. Patients are only required to contribute a nominal payment themselves. Over-the-counter medication, which is available without a prescription, is not covered by statutory health insurance. However, children under the age of 12 and, in certain cases, adolescents can be prescribed medication by a doctor without a receipt and have the cost of this medication covered. In addition, statutory health insurance funds also cover over-the-counter medication if it is the standard therapy used to treat a health condition.

Restrictions and exceptions

There are also some prescription drugs that are not covered by statutory health insurance funds as a matter of principle. These include lifestyle products such as potency-enhancing drugs and appetite suppressants.

Other medications are not covered by the insurance funds because there is no or insufficient proof of their benefits, or because their cost is disproportionate to the benefit offered. The pharmaceutical guidelines issued by the Joint Federal Committee (Gemeinsamer Bundesausschuss, G-BA) specifies which prescription drugs are covered by statutory health insurance. The G-BA is the supreme decision-making body of the self-governing organization within the healthcare system in Germany.

Reference prices apply to certain drugs. This is the case, for example, if there are cheaper drugs available that offer identical therapeutic benefits. For these drugs, maximum prices (reference prices) are determined, which indicate the maximum amount that will be covered by statutory health insurance.

This means that, when issuing a prescription, doctors can choose between several different drugs with the same therapeutic value that will be covered by the statutory health insurance funds. However, if a doctor chooses to prescribe a drug that exceeds the reference price, the patient will have to cover the cost of the difference. Co‑payments also apply to prescriptions covered by statutory health insurance.

Reimbursement of costs in private health insurance

People with private health insurance initially pay the full price for prescription drugs in pharmacies. They can then apply to their insurance provider for a reimbursement of the cost based on the prescription and the receipt from the pharmacy. The person’s individual level of cover and schedule of benefits determine which drugs are covered.

For prescription drugs, patients with statutory health insurance are usually required to contribute a co-payment of 10 percent per pack, subject to a minimum of 5 euros. The upper limit is 10 euros.

If the drug costs less than 5 euros, the full price is covered by the patient themselves. Medication for children under 18 years of age and medication to be taken in conjunction with pregnancy or birth are also available without co-payment. In addition, statutory health insurance funds may also exempt a range of low-priced drugs from co-payment. These are referred to as “co-payment-exempt”.

Lists of co-payment-exempt drugs are provided on the website of the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband).

If an individual’s co-payments exceed a certain portion of their annual income, they are eligible for exemption from additional co-payments.

Pharmacies sometimes give people with statutory health insurance a medication that differs from the one specified on the prescription. This is a cheaper alternative with the same active ingredient, a comparable dosage form and the same potency (strength). In most cases, prescriptions simply specify an active ingredient, leaving the pharmacy free to chose the best-value option for the patient. The statutory health insurance funds have often negotiated price reductions for these drugs. Pharmacies are then obliged to dispense the drugs manufactured by companies with which the health insurance fund has concluded a discount agreement.

This provision is known as the “aut idem rule” (meaning “or the same”). All prescriptions covered by statutory health insurance include a box labeled “aut idem”. If this is not crossed out, the pharmacy is required to find a low-price alternative containing the same active ingredient. If a patient insists on a specific product, they are required to cover any additional costs themselves. Doctors may prevent product substitution for medical reasons. This happens, for example, if a patient has allergies to certain ingredients. In this case, they simply cross out the “aut idem” box on the prescription.

If you have any questions about how drugs may be substituted by pharmacies or about co-payment and insurance cover, the Independent Patient Advice Service for Germany (Unabhängige Patientenberatung Deutschland, UPD) is a source of useful advice and support.