Differentiated co-payment: 10 or 40 per cent

What is the differentiated co-payment?

It is a raised cost share on expensive originator products. The rate is 40 instead of 10 per cent when cheaper interchangeable products exist in the same active substance group of the Specialities List. The aim is to steer patients towards the cheaper product without removing reimbursement of the originator altogether.

The legal bases are Art. 64 of the Health Insurance Act for cost sharing and Art. 38a of the Health Care Benefits Ordinance for the raised rate. Which products are affected follows from the Specialities List itself, where the FOPH flags the medicines carrying the raised co-payment.

How does the FOPH calculate the threshold?

The FOPH sets a price threshold inside each active substance group: the average of the cheapest third of the products in that group, computed on the ex-factory price per daily dose or pack unit. Originators above the threshold move to 40 per cent, products below it stay at 10 per cent.

1. Form the active substance group: all interchangeable products with the same substance, the same pharmaceutical form and comparable strength.
2. Make prices comparable, so that different pack sizes do not distort the result.
3. Identify the cheapest third of the group and calculate their average price.
4. Apply that threshold to every product in the group and flag those above it in the Specialities List.
5. Recalculate whenever a price changes or a product joins or leaves the group.

Since the 2024 revision the threshold also covers biosimilars: if a cheaper biosimilar exists in the group, the reference product can likewise attract the raised co-payment. Before that the rule applied in practice only to small molecule generics.

How do franchise and co-payment interact?

The insured person first pays the chosen franchise in full, at least CHF 300 per calendar year for adults. After that the insurer pays the costs less the co-payment of 10 or 40 per cent. The co-payment is capped annually; the franchise comes on top and is not counted inside that cap.

• Franchise: freely chosen, from CHF 300 for adults; children can have a zero franchise.
• Co-payment: 10 per cent as a rule, 40 per cent for flagged originator products.
• Annual co-payment ceiling: CHF 700 for adults, CHF 350 for children.
• Once the ceiling is reached, no further percentage share may be charged on medicines.
• The hospital contribution of CHF 15 per day for adults is separate and does not count towards the ceiling.

Worked example: what does choosing the originator cost?

The following figures are freely chosen and serve only as an illustration. They show the force of the raised rate: with an originator at CHF 120 and a generic at CHF 60, the insured person pays CHF 48 instead of CHF 6 per pack once the franchise is used up.

Note that the raised co-payment falls on the insured person, not on the authorisation holder. In long term therapy the CHF 700 ceiling is often reached within the first half of the year, so the real burden depends heavily on individual consumption.

Which medical exceptions apply?

If dispensing the originator is medically necessary, the co-payment stays at 10 per cent. The prescriber has to justify and document that necessity, for instance intolerance of an excipient, a narrow therapeutic window, or documented instability after an earlier switch.

• Intolerance of or allergy to an excipient in the cheaper product.
• Substances with a narrow therapeutic index, where switching creates a concrete risk.
• Documented problems after a previous switch, recorded in the clinical course.
• No suitable pharmaceutical form or strength available in the cheaper product.
• The note belongs on the prescription; the pharmacy then bills 10 per cent.

What must the pharmacy tell patients?

The pharmacy must explain the raised co-payment before dispensing and point out the cheaper products available. Under Art. 52a of the Health Insurance Act it may substitute unless the prescription excludes substitution; the patient decides after being informed, and the pack dispensed is documented.

• Flag the 40 per cent co-payment and the concrete franc amount that follows from it.
• Offer at least one cheaper interchangeable product from the same active substance group.
• Query the practice when substitution is excluded but not justified.
• Record the information given and the patient's choice in the medication file.