Reimbursement of pharmaceuticals

Discount rates for pharmaceuticals

EHIF reimburses to a certain extent for prescription medicines, the effectiveness of which has been previously thoroughly assessed and therefore they have been included in the list of reimbursed pharmaceuticals. These pharmaceuticals are available at a 50, 75, 90 or 100% discount. The highest discount rates are available for principal pharmaceuticals needed to treat serious and chronic diseases, or for certain groups of the population (old-age and incapacity pensioners).

The buyer has to pay a prescription fee of 2.5 euros for each prescription medicine. 

The EHIF discount is calculated on the remaining part of the price according to the prescribed percentage. This means that the patient has to pay for the part exceeding the discount amount.

If there are many pharmaceuticals with the same active ingredient by different manufacturers on the market, a reference price is set for the whole group of pharmaceuticals with the same active ingredient, and the EHIF discount is calculated on this reference price. For example, if a pharmacy has a selection of medicines with the same active ingredient at the price of 5.60, 8.30, 10.50 and 12.80, the price of the second cheapest medicine (8.30 in this example) is used as the reference price and the EHIF discount is calculated on this amount. If the buyer prefers a more expensive medicine, then in addition to the basic rate (2.5 euros) and mandatory contribution, he/she must also pay for the part exceeding the reference price. Therefore, it is worth asking your pharmacist which medicine with the same active ingredient is sold at better price.

Reimbursement principles and list

The EHIF’s list of reimbursed pharmaceuticals established by a regulation of the Minister of Social Affairs and it is amended four times a year. The list includes pharmaceuticals that have a valid marketing authorization in Estonia and are subject to discount when purchased in a pharmacy.

If there are many pharmaceuticals with the same active ingredient by different manufacturers on the market, a reference price is set for the whole group of pharmaceuticals with the same active ingredient, and the EHIF discount is calculated on this reference price (100%, 75% or 50%).

To ensure stable marketing of pharmaceuticals and to prevent price increases, EHIF signs pricing agreements with pharmaceutical companies. Pricing agreements are signed for pharmaceuticals that are the only ones of their kind (with the same active ingredient and route of administration) and are included in the list of reimbursed pharmaceuticals. A pricing agreement is signed also for those pharmaceuticals that are in their price group cheaper than or equal to the reference price. 

Only those pharmaceuticals that are indicated for the treatment or alleviation of diseases specified in the regulation of the Government of the Republic will be entered in the list of reimbursed pharmaceuticals.

100% discount

Patient pays the deductible of 2.50 euros and the amount exceeding the reference price or agreed price. EHIF reimburses 100% of the remaining price of pharmaceutical.  

100% discount rate applies to pharmaceuticals indicated for the treatment of serious, life-threatening or epidemic diseases or the disease that cause severe pain. In addition, the 100% discount applies to all patients under 4 years of age. Please note! This does not apply to the prescription of iron prelates and food mixtures, in which case the conditions for age and diagnosis given separately in the list of medicinal products apply.

90% discount

Patient pays the deductible of 2.50 euros and the amount exceeding the reference price or agreed price. EHIF reimburses 90% of the remaining price of the pharmaceutical.

In some cases, the buyer of a pharmaceutical sold at 75% discount can use the 90% discount rate instead. The 90% discount rate applies to pharmaceuticals prescribed for children aged 4-16, persons receiving an incapacity for work or old-age pension and insured persons aged 63 and older.

75% discount

Patient pays the deductible of 2.50 euros and the amount exceeding the reference price or agreed price. EHIF reimburses 75% of the remaining price of the pharmaceutical.

The 75% discount applies to pharmaceuticals that are primarily indicated for the treatment or alleviation of chronic diseases. 

50% discount

Patient pays the deductible of 2.50 euros and the amount exceeding the reference price or agreed price. EHIF reimburses 50% of the remaining price of the pharmaceutical.

The 50% discount rate applies to all other pharmaceuticals entered in the list of reimbursed pharmaceuticals that are indicated for the treatment of diseases that are not directly life-threatening, severe or chronic, or are used when the patient does not have a specific diagnosis. A 50% discount rate usually applies in case of mild illnesses that normally do not require long-term treatment (such as antibiotics).

Discount rates and calculation of reimbursement

Choose a discount rate:
Patient pays:EHIF pays: Price of pharmaceutical: Regerence price
18 €
Patient pays
2.50 €
Graph
Calculation of the price of pharmaceuticals at the 100% discount

Patient pays the deductible of 2.50 euros and the amount exceeding the reference price or agreed price. EHIF reimburses 100% of the remaining price of the pharmaceutical.    

payed by EHIF
payed by patient

More information:

Additional benefit for pharmaceuticals

From the beginning of 2018, supplementary benefits for people with high expenses on medicinal products will start. Supplementary benefits for medicinal products are provided to insured persons who pay at least EUR 100 per the calendar year for discount prescriptions (so far they received benefits from the expenses of EUR 300 per year). The benefit is meant to help those who spend more money than average for the purchase of discount medicines. For example, people who need to use expensive medicines or people with chronic illnesses who have to take medication over an extended period of time or more than one medicine at a time.

From the beginning of 2018, the supplementary benefit for medicinal products is automatic, the insured person will receive additional benefits, along with the usual medical benefit, at the time of purchase of the drug at the pharmacy, and submission of an application to the Health Insurance fund is not required.

How is the supplementary benefit for medicinal product calculated?

The supplementary benefit for medicinal products applies to expenses on discount medicinal products. This means that the costs of over-the-counter medicines (non-prescription drugs) and prescription drugs that do not qualify for a health insurance fund benefits, or medical devices are not taken into account.

Supplementary benefits for medicinal products is calculated on the basis of expenses accrued per the calendar year.

The following principles apply to the benefits of medicines purchased with discount prescriptions:

  • If the amount remains below EUR 100 per year, no supplementary benefit for medicinal products
  • If the amount is EUR 100-300 per year, 50% of the amount exceeding EUR 100 will be compensated for
  • If the amount exceeds EUR 300 per year, 90% of the amount exceeding EUR 300 will be compensated for

The Health Insurance Fund will start compensating for costs starting from EUR 100 euros.  In the range between EUR 100-300, a 50% discount will apply. For example, if a person has spent EUR 250 on medicinal products, he or she will receive a discount of 75 euros from the Health Insurance Fund. In cases of expenses exceeding EUR 300 euros, the Health Insurance Fund will pay 90% of the cost. For example, if a person has spent EUR 500, he or she will receive a discount of EUR 280.

Calculation of the supplementary benefit for medicinal products

  1. First, the initial amount of the supplementary  benefit for medicinal products for the calendar year is calculated:

Base amount of the supplementary benefit for medicinal product

NB! This amount is always lower than the amount spent on discount prescriptions.

The amount spent on discount medicines

The costs of over-the-counter medicines, medical devices, and non-discount medicines will not be taken into account.

The part of the price of medicines that exceeds the price of a reference price or the  price agreement price

1. If the base amount of the supplementary benefit of the medicinal product is known, the supplementary benefit for the medicinal product will be calculated as follows:

Base amount of the supplementary benefit for medicinal product

NB! This amount is always lower than the amount spent on discount prescriptions.

The amount spent on discount medicines

The costs of over-the-counter medicines, medical devices, and non-discount medicines will not be taken into account.

The part of the price of medicines that exceeds the price of a reference price or the  price agreement price

2. If the base amount of the supplementary benefit of the medicinal product is known, the supplementary benefit for the medicinal product will be calculated as follows:

The amount spent on medicinal products

 

The Health Insurance Fund will compensate

 

 

Example

 

Less than 100 euros

 

Supplementary benefit for medicinal products is not taken into account

 

Supplementary benefit for medicinal products is not taken into account

 

100 to 300 euros

 

50% of the amount exceeding EUR 100

For example, if a person purchases a number of discount medicines in a calendar year and with this purchase, the base amount of his or her personal amount of supplementary benefit for medicinal products will increase to EUR 105, then he or she will be granted a supplementary benefit of 50% for the EUR 5 exceeding the EUR 100, and the person will pay EUR 2.5 less in the pharmacy. If a person has spent EUR 250 on medicines, we will deduct EUR 100 from this amount for the additional benefit, which is the minimum payment threshold, and we will make a calculation of 150x50% = EUR 75.

More than 300 euros

 

90% of the amount exceeding EUR 300

 

If the base amount of the supplementary benefit for medicinal products was 300 before the purchase and a medicinal product was purchased, which raised the base amount to 320, the supplementary benefit will be paid at 90% of the amount exceeding EUR 300  (90% of 20 = EUR 18) and the person will pay 18 euros less in the pharmacy . It is essential to keep in mind that from 100 to 300 euros, 50% benefit has already been received from previous purchases.

However, if before the purchase, the base  amount was EUR 90, and an expensive medicine was purchased, which raised the base amount to EUR 500, a person will receive a supplementary benefit of EUR 280 (i.e., 50% of the difference of EUR 100 and EUR 300 (EUR 100) + 90% of the amount which exceeds EUR 300 (90 % from 200 = EUR 180)

NB!  The amount exceeding the reference price or the agreed price or the avoidable cost-sharing will be deducted from the amount spent on medicinal products before calculation of the supplementary benefit for the medicinal products.  If there are many medicinal products with the same active substance in the market from different manufacturers, a reference price for the whole group of medicines with the same active substance will be established, from which the EHIF discount will be calculated.  For example, if a pharmacy has a selection of medicines with the same active substance at a price of EUR 5, EUR 7 and EUR 9, then the reference price will generally be the price of the second most affordable medicine (for this example, EUR 7) and a the benefit percentage of the Health Insurance Fund will be calculated from this amount.  In case the purchaser of a medicinal product prefers more expensive medicine, the part exceeding the reference price must be paid in the pharmacy in addition to the established cost sharing.

Very rarely, it may occur that even though a person has the right to receive supplementary benefits, it is not possible to make an additional discount for this (as may happen, for example, at the end of the year), then a person will receive a higher benefit in the following calendar year.

From January 1, 2018, all prescriptions will have a regular prescription fee of EUR 2.5. For example, if a person with diabetes previously was able to obtain a prescription with a 100% discount (equal to the reference price) for EUR 1.27, then from the beginning of 2018 they will be charged EUR 2.5 for the prescription. The same change applies to medicines for children under the age of 4 years. On the other hand, if previously EUR 3.19 had to be paid for an antibiotic with an (equal to the reference price) 50% discount for the treatment of inflammation/infection, it will now become more favorable, and the prescription will cost 2.5 euros + 50% of the price of the medicinal product.


For information about calculating your additional benefit for medicinal products check the State Portal at eesti.ee