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Prescriptions, hospitalisation, etc.: how much do I have to pay, and what will the health insurance fund pay?

Getting your medication with a doctor’s prescription from a pharmacy right away, without having to pay for it? Sometimes it works, sometimes it doesn’t. In many cases, patients in Germany are required by law to pay a mandatory supplement – not only for their medication, but also for treatments at hospitals, personal care at home, physiotherapy and other healthcare services. Few people understand how the provisions on mandatory supplemental payments really work. We would like to shed some light on the issue:

Pink or green? This is what you can expect:

In the first instance, a distinction is made in Germany between prescription medication and OTC medicines. ‘OTC’ of course means ‘over the counter’. In other words, the medicine is sold without a prescription, but will not be paid for by the statutory health insurance fund. The green prescription provided for this purpose serves only as a recommendation by the doctor.

Pink prescriptions, on the other hand, are used for medication that must be prescribed by a doctor. Patients are required to pay a contribution for all of these medications. Depending on the price of the medication, the patient’s contribution may vary, but it’s always 10% of the price and ranges between a minimum amount of € 5.00 and a maximum amount of € 10.00, even if the medication costs more than € 100.00. If a medication costs less than € 5.00, the insured person only pays the actual price.

Discount agreements – now this is tricky

So far, so good. But now things get really confusing: some statutory health insurance funds and pharmaceutical companies conclude discount agreements. As a result, statutory health insurance funds can get better conditions, while pharmaceutical companies may expect higher turnovers.

For every prescription, the pharmacy will check whether the patient’s statutory health insurance fund has concluded a contract for a drug that has the same active ingredient as the prescribed medication. Very often, that will be a generic product. They are no less effective than the brand name drugs. The generic products can be offered at a lower price because they do not require studies on the safety and effectiveness of the preparation. Apart from proof of quality and bio-equivalence, they only require verification that the generic product contains the same active ingredient as the branded product. The benefit for patients: no supplemental payment is required for very cheap medication. This applies specifically to medication, where the price is at least 30% below the fixed amount which the statutory health insurance funds would reimburse for the medication.

What about the other benefits?

For full inpatient treatment at a hospital, those with insurance must pay € 10.00 per day for a maximum of 28 days. The same applies to follow-up rehabilitation – in which case the duration of the previous hospitalisation counts towards the overall number of days. For personal care at home, those with insurance must pay a contribution of 10% of the costs for the first 28 days. For home help, the following applies: 10% of the costs per day, subject to a minimum amount of € 5.00 and a maximum amount of € 10.00. For an overview of all required supplemental payments compiled by the AOK, please see here.

Who is exempt?

Children up to the age of 18 are exempt from the payment of a supplement; pregnant women are excluded as well, provided the service is related to pregnancy disorders. To avoid a disproportionately heavy burden on anyone, a capacity limit applies. This limit is fixed for adults at 2% of their annual gross income; patients with severe chronic illnesses have a limit of 1%. For a quick and easy calculation of your capacity limit, please use this capacity limit calculator.

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