Additional benefit for pharmaceuticals
An additional benefit for pharmaceuticals is monetary compensation payable to an insured person as monetary compensation in addition to the drug discount received from the pharmacy. This can be paid if the conditions for payment of compensation are fulfilled.
The Health Insurance Fund makes the payments of this benefit four times a year: in January (for the previous calendar year), April, July and October.
In particular, the supplementary benefit for medicinal products helps to compensate the cost of pharmaceuticals for persons:
• whose treatment plans include expensive medicinal products;
• who suffer from chronic conditions and, consequently, need to use medicinal products for a long period of time;
• who have to use several medicinal products at a given time.
NB! The procedure for calculation of discount prescriptions changes as of 01.01.2015.
How is the additional benefit for medicinal products calculated?
1) First, the base amount of the additional benefit for medicinal products is calculated for a calendar year:
The base amount of the additional benefit for medicinal products N.B.: This amount is always lower than the amount spent on discount prescriptions | = | The amount spent on discount prescriptions The expenditure made on the over-the-counter medicines, and non-discount prescription medicines are not taken into account. | _ | Mandatory co-payment per prescription. Per one prescription: - in case of 100%, 90% and 75% discount EUR 1.27; - in case of 50% discount EUR 3.19 per one prescription; + The share of the price of medicines, which is higher than the limit price or the agreed price. |
2) If the base amount of the additional benefit for medicinal products is known, the additional benefit for medicinal products will be taken into account as follows: (select the appropriate period)
In case of discounted prescriptions purchased before 01.01.2015 the following calculation principles apply:
Base Amount (See poin 1) | The Health Insurance Fund will compensate... | Example |
Less than 384 euro | Additional benefit for medicinal products will not be paid | Additional benefit for medicinal product will not be paid |
384 - 640 euro | From the part exceeding 384 euro 50%
| E.g., base amount 500 euro - the amount of compensatio is (500 - 384) x 50% = 58 euros |
640 - 1300 euro | For the range of 384 - 640 euro 50% or 128 euro and in addition from the amount exceeding 640 euro 75% | E.g., base amount 1000 euro - the amount of compensation is 128 + (1000 640) x 75% = 398 euro |
More than 1300 euro | Additional compensation will not be paid for the amounts exceeding EUR 1,300 - in such a case, the rate of additional benefit of medicinal products will remain 623 euro | E.g., base amount 1500 euro - will be compensated for to the maximum extent 623 euro |
In case of discounted prescriptions purchased after 01.01.2015 the following calculation principles apply:
Base Amount (See point 1) | The Health Insuranc Fund will compensate... | Example |
Less than 300 euro | Additional benefit for medicinal products will not be paid | Additional benefi fo medicinal products will not be paid |
300 – 500 euro | 50% from the part exceeding 300 euro | E.g., base amount 400 euro - the amount of compensation is (400300) x 50% = 100 x 50% = 50 euro |
More than 500 euro | 90% from the part exceeding 500 euro, there is no rates per calendar year anymore. | E.g., the basic amount 1000 euro - the amount of compensation is ((500- 300) x 50%) + ((1000 – 500) x 90%) = 100 + 450 = 550 euro |
Submission of an application for additional benefit for medicinal products
For the entitlement of the annual benefit, it is sufficient if the insured person or his or her legal representative has submitted a relevant application to the Health Insurance Fund.
You can submit the application:
● Via the service of the State Portal
● submit the application to the Health Insurance Fund: bring or send by mail to the customer service office, or digitally signed to the address info [at] haigekassa.ee