Understanding SL limitations

A limitation is a reimbursement condition written into the SL entry. It can narrow the indication, require a patient group or prior therapy, cap dose and treatment duration, set a maximum quantity or require cost approval from the insurer (Art. 73 of the Health Insurance Ordinance).

For limitations that require cost approval, the treating physician must file a request with the health insurer before starting therapy. The insurer's medical adviser checks whether the limitation's conditions are met and the insurer confirms in writing, often for a fixed period and with follow-up requirements.

Then basic insurance has no obligation to pay. If the therapy is still medically necessary, individual case reimbursement under Art. 71a-d of the Health Insurance Ordinance can be assessed; that requires a high expected therapeutic benefit and a price agreement with the authorisation holder.