PrEP: cost coverage by health insurance

To have the costs for HIV PrEP covered by compulsory health insurance, you must meet four conditions: 

1. You have health insurance in Switzerland.
2. You meet the cost coverage criteria.
3. Your healthcare professional is affiliated with SwissPrEPared.
4. Your healthcare professional is authorised to bill through health insurance.

If your healthcare professional is not affiliated with SwissPrEPared, there are three options: 

1. Your healthcare professional joins SwissPrEPared. All relevant information can be found online.
2. You stay with your doctor but pay all the costs yourself without going through your insurance.
3. You switch to a SwissPrEPared centre. For individuals under the general practitioner (GP) model, the telemedicine model or a similar model, a permanent referral is required.

PrEP might still be a good option for you individually – talk to a healthcare professional about it. However, you would need to fully cover the costs yourself in this case.

The costs for PrEP consist of the medication itself, medical services and laboratory analyses. 

If PrEP is taken daily, these costs amount to approximately CHF 2,000 to CHF 2,500 per year. The costs – minus the cost-sharing components – are covered by the health insurer.

All medical services in Switzerland are associated with certain costs – and this also includes PrEP. Cost-sharing is comprised of three components:

1. Premium: You pay a monthly contribution. The premium amount depends on various factors, such as where you live. Check whether you would be entitled to a premium reduction in your canton of residence.
2. Deductible: You can decide each year how much you are willing to pay yourself. Your health insurance will then cover the rest. You can choose between CHF 300 and CHF 2,500. The higher the deductible, the lower the monthly premium.

Retention fee: Once you have paid your deductible, you will be charged 10% of your healthcare costs on an ongoing basis, up to a maximum of CHF 700 per year.

No. HIV PrEP is covered under basic insurance, which means every health insurer has to pay for it if you meet the criteria.

Possibly. In any case, choose either the lowest (CHF 300) or the highest (CHF 2,500) deductible; anything in between is financially disadvantageous. You can adjust your deductible for the following year until 30 November.

Depending on your health situation, the lowest deductible may make more financial sense: HIV PrEP taken daily incurs healthcare costs of CHF 1,700-2,500; if taken irregularly, the costs are lower. If there are other costs in addition to taking PrEP daily, e.g. STI treatment or psychotherapy, the lowest deductible is financially worthwhile for you - even if the monthly premium is then higher.

Generally speaking, yes. However, not all doctors offer the option of paying for treatment yourself.

That’s not an ideal situation. In Switzerland, everyone is required to have health insurance by law.

If you have health insurance abroad, you can find out whether it covers the costs of PrEP in Switzerland.

You can cover the PrEP costs in full yourself. In some cities, there are specialist health services for people who don’t have health insurance. 

There are counselling centres for undocumented migrants (“sans papiers”) on the subject of health insurance.  

For sex workers, some sexual health centres offer special conditions.

That’s tricky under the Swiss system. But there are certainly ways to prevent your parents from finding out. Health insurance companies are bound by law – data protection and medical confidentiality also apply to you in relation to your own parents.

You can get anonymous and free advice from a sexual health centre, and we can also help you talk to your parents about your situation.

No, your participation in SwissPrEPared does not affect whether the PrEP costs will be covered. Even so, only medical practices, hospitals or healthcare centres affiliated with SwissPrEPared can bill through health insurance.

Your personal data collected by SwissPrEPared is not shared.

However, for cost coverage purposes, your health insurer may check with your healthcare professional whether you come under one of the eligible groups and, if so, which one. The corresponding information may be shared with the health insurer. Such medical information may only be passed on to the trust medical service. The health insurance company only receives the information that you are taking PrEP.

Yes, because social services only pay costs for which a bill can be provided, and the name of the medication appears on the bill. This information, however, must not be used or disclosed under any circumstances. It is protected by strict data privacy laws. If you have any questions or issues, you can contact the legal advice service of the Swiss AIDS Federation.

Yes. Doctors can prescribe PrEP in what is known as off-label use. But the health insurance does not cover the costs of the medication for off-label use.

This is currently being clarified by the legal service of the Swiss AIDS Federation (as of July 2024).

For many people in Switzerland, healthcare costs are a significant burden.

Be sure to check whether you would be entitled to a premium reduction in your canton of residence. Especially if you have other healthcare costs as well, a low deductible is worthwhile financially – even if it means higher monthly payments.

The prescribing doctor should write to the health insurer to make them aware of the need for the medication as well as their legal obligation to cover the costs.

In the case of disagreement, the Ombudsstelle Krankenversicherung can help.

If this doesn’t work, the doctor can contact the legal service of the Swiss AIDS Federation

From July 2024, PrEP users will need to visit a SwissPrEPared centre to get PrEP through their health insurance. Nevertheless, users do not have to participate in the SwissPrEPared programme or the study.

Due to this change, PrEP will no longer be available in some regions of Switzerland. Also, there are likely to be some GPs and other doctors, presumably mostly in urban areas, who currently prescribe PrEP but are not affiliated with SwissPrEPared.

This could lead to increased demand. Be prepared for this. It is crucial to ensure uninterrupted access to PrEP, even for clients who have switched over to you. Play your part in making sure there are no supply problems.

Yes. Centres interested in participating should contact SwissPrEPared as soon as possible.

New centres are expected to accept a minimum number of patients. GPs with a small number of PrEP users are advised to issue referrals to SwissPrEPared centres.

Absolutely. Ideally, you should offer both a compulsory health insurance and a self-payment option for PrEP. There will be clients who for personal, financial or legal reasons can’t or don’t want to go through compulsory health insurance. It is important that PrEP remains available to these individuals too.

The combination drug tenofovir 245mg/emtricitabine 200mg is recommended. Health insurance only covers the costs of medicines that are included in the Spezialitätenliste/Liste des spécialités. These are the products from Mepha and Viatris (as of 15 July 2024). The maximum reimbursement price is set at CHF 72.-. 

The product is available for only CHF 49.- via the Schaffhauserplatz pharmacy online shop (www.swissprep.ch). Inform patients accordingly to save costs.The maximum reimbursement price is also specified there.

Yes. Medical consultations can be delegated to support staff if the responsible physician is available, meaning the supervising person must be present and on site in person.

To be able to bill through compulsory health insurance, the supplier must be an authorised service provider. It is not enough to merely be affiliated with SwissPrEPared. The rules on this differ by canton.

In the field of medical practice, sexual health and sexuality are still highly stigmatised topics. Recent studies by the FOPH have shown that sexual minorities in particular face significant challenges relating to trust, access and resources within the healthcare system.

It is therefore crucial that healthcare professionals create a reliable, trustworthy and safe environment. For example, young adults who are still covered under their parents’ health insurance must be adequately informed about it.

However, there might be instances where health insurers ask for justification of the costs before they can cover them. Strictly speaking, only the medical review service of the insurance company should request this information. In practice though, you will often be contacted by other departments. Never tell them any very personal details about your sexual behaviour. Instead, ask that the medical review service submits a written request for the justification of the cost coverage.

Also, do not disclose the entire case history, but only what is necessary for justifying the costs.

The current guidelines can be found on the SwissPrEPared website. If you have any questions, you should contact the infectious disease consultation service at your local hospital.

The participating centres can be found on the SwissPrEPared website.