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SummaryWhether a medicine is paid for by statutory health insurance in Germany, and how much, is not decided product by product at the counter. It follows the rules of the Fifth Social Code, the SGB V. Understanding those rules is the starting point for pricing, market access and correct dispensing.
Insured patients are entitled to medicines as part of their care under the SGB V. In principle this covers prescription medicines. Over-the-counter products are generally excluded, with defined exceptions such as certain treatments for children or specific therapy standards set by the Federal Joint Committee.
For many products, statutory insurers do not reimburse the full price but a Festbetrag, a reference amount set under section 35 SGB V for a group of comparable products. If a medicine costs more than its fixed amount, the patient pays the difference on top of the normal co-payment.
For newer, patent-protected medicines that have passed benefit assessment, a negotiated Erstattungsbetrag under section 130b SGB V applies. In the generic and off-patent space, Rabattvertraege under section 130a determine which product an insurer actually reimburses. On top of all this sits the patient Zuzahlung, the statutory co-payment.
Reimbursement status is not static: fixed amounts change, contracts are re-tendered, and negotiated prices are updated. To dispense correctly and to plan market access, you need current reimbursement data per PZN and molecule. pharmazie.com brings pricing, reimbursement and article master data together in one search. See also our solution for rebates and reimbursement.
