This document, issued by the Swiss Federal Office of Public Health (BAG), outlines the scope of cost coverage for medical preventative measures under the Mandatory Health Care Insurance (OKP). The OKP covers measures that meet the criteria of effectiveness, suitability, and economic viability (WZW criteria), as stipulated in Articles 12a through 12e of the Ordinance on Healthcare Benefits (KLV). These categories include prophylactic vaccinations, general disease prophylaxis, health check-ups, and early detection measures for both specific risk groups and the general population. The process for integrating new preventive services requires application and review by the Federal Commission for General Benefits and Fundamental Questions (ELGK), followed by a final decision by the Federal Department of Home Affairs (EDI). Detailed regulations are provided concerning prophylactic vaccinations (Art. 12a KLV), emphasizing the distinction in coverage based on medical indication (excluding occupational/travel medicine) and the location of service delivery, particularly regarding vaccinations performed in pharmacies.
Swiss Mandatory Health Insurance (OKP) Coverage for Medical Prevention Measures
0:00 Coverage Criteria and Scope: The OKP assumes costs for specific preventative measures that have been rigorously tested for Wirksamkeit (effectiveness), Zweckmässigkeit (suitability), and Wirtschaftlichkeit (economic viability).
0:18 Covered Measures (KLV Articles): The OKP covers preventative measures listed in Articles 12a through 12e of the Krankenpflege-Leistungsverordnung (KLV, Ordinance on Healthcare Benefits):
Art. 12a KLV: Prophylactic vaccinations.
Art. 12b KLV: Measures for disease prophylaxis.
Art. 12c KLV: General health status examinations.
Art. 12d KLV: Early detection in specific risk groups.
Art. 12e KLV: Early detection in the general population.
0:45 Regulatory Approval Process: The introduction of new preventative services into the KLV requires an application to the Eidgenössische Kommission für allgemeine Leistungen und Grundsatzfragen (ELGK), which assesses the WZW criteria and provides a recommendation to the Federal Department of Home Affairs (EDI). The EDI determines the final obligation for coverage.
0:54 Prophylactic Vaccinations (Art. 12a KLV): Costs for medically administered vaccinations are covered (subject to deductible and retention), provided the vaccine is listed in the Specialities List (exceptions: HPV and Mpox vaccines).
1:09 Exclusions: Costs incurred for vaccinations related to occupational requirements or travel medicine are explicitly not covered by the insurance.
1:15 Pharmacy Vaccinations (General Rule): If a vaccination is administered in a pharmacy without a doctor's prescription, the costs for both the vaccine and the administration act are not covered by the OKP and must be borne entirely by the insured person.
1:25 Pharmacy Vaccinations (with Prescription): The Federal Office of Public Health (BAG) interprets the current law—in view of parliamentary support for Cost Reduction Package 2—to mean that if a vaccine is prescribed by a doctor and dispensed by a pharmacy, the OKP will cover the cost of the vaccine itself.
1:36 Coverage for Administration Act: The administration act (Verimpfung/Verabreichung) performed in a pharmacy is not covered by the OKP and must be paid by the insured person, even with a prescription. OKP coverage for the administration act occurs only if it is performed in a doctor's practice or a hospital.