Patients are eligible for a certain amount of coverage for the expenses related to their medical care, including medications prescribed at outpatient departments, nutrition supplements for patients with special nutrition needs and the price, rental and reparation fees of transient and permanent medical aids.
In Hungary, medications can be divided into two groups based on their social security coverage. In the case of “social security covered” medications there is a certain percent of social security coverage on the full price and patients have to pay a lower price, while in the cases of those with no social security coverage (“uncovered medications”), patients are obliged to pay the products’ full price (consumer price).
The social security insurance provides a coverage on medications if the medication is prescribed by a doctor and the adequate social security coverage category is indicated on the prescription. Medications prescribed by a doctor without any social security coverage (“uncovered medications”) can be purchased at consumer prices which may vary depending on the producer.
Social security covered medications can be purchased at a reduced price. The social security covered price is calculated by deducting the amount of the social security coverage from the product’s consumer price. Covered medications have a universal price, which means that pharmacies cannot determine a higher price than the price determined by the National Health Insurance Fund of Hungary (NEAK). The amount of coverage is also universal (also determined by the NEAK).
What is the amount of the coverage applied on medications?
Coverage can be determined in a fix amount of money or in a percentage.
Depending on the indicated percentage, the social security insurance provides 80, 55 or 25% coverage on the gross consumer prices of the medications.
- Above average coverage category, normative 80% coverage is provided on medications used for the cure of severe, chronic diseases and conditions with exceptional epidemiological importance.
- Average coverage category, normative 55% coverage is provided on medications used for the cure of moderately severe, chronic diseases and conditions.
- Below average coverage category, normative 25% coverage is provided on medications used for the cure of chronic diseases and conditions that temporarily or permanently impair the ability to cover basic needs.
Some medications fall into the no coverage category (0%), which means there is no social security coverage on some medications ordered and purchased by medical service providers, and those medications for which the NEAK does not provide coverage.
Medical indication related coverage
Emphasized, 100% coverage: medications taken continuously or lifelong for chronic diseases or chronic prevention fall within this coverage category. Patients have to pay a 300 HUF copayment fee per each package of medication within this emphasized indication coverage category, therefore even with the 100% coverage, the patients have to pay a symbolic copayment (sometimes also called “box fee”). The copayment does not have to be paid in case of occupation-related diseases.
Raised 90%, 70%, 50% coverage: medical indication related medications within the “so called” raised indication coverage category are medications taken continuously or lifelong in chronic diseases and disorders, moderately severe chronic illnesses and for diseases which are severe but require shorter medical treatment.
Some of the medications within these categories are only available for hospital treatments or at outpatient departments, and are covered 100% by the social security insurance.
A distinct coverage category is the so called no coverage value coverage category, in which medications are only available for medical service providers.
How can you purchase a medication with price coverage?
You can purchase medications with price coverage if the medication is prescribed by a doctor who is entitled to prescribe medications with price coverage and the type of price coverage is indicated on the prescription since it is supposed to be ordered according to legal regulations., In such cases, the medication can be purchased at pharmacies with special NEAK-contracts, enabling the refund of the coverage.
Possible prescription titles of medication coverage categories
On the prescriptions, there is a special, designated field where doctors can indicate the appropriate medication coverage category. This field must be marked with an X. When purchasing medications or medical aids, this will indicate the social security coverage category to which the patient is entitled to.
Possible prescription titles:
- Normative: 80, 55, 25 or 0% coverage can be applied to medications depending on the type of the disease. The extent of the support is determined by the NEAK.
- Individual coverage: Individual coverage can be applied on medications, nutritional supplements and medical aids which normally would not be covered by social security insurance, or they have no valid marketing authorization in Hungary, but they are necessary for the successful treatment of the patient, or the treatment can only be implemented with medications that are usually applied in other diseases. Individual coverage must be requested at the National Health Insurance Fund of Hungary (NEAK).
- Coverage for civil employees and soldiers working for the Hungarian Defence Forces.
- Public health coverage. This is a social support-based coverage category that can be availed with a predetermined budget. (Emphasized and raised coverage categories can be applied at the same time within the scope of public health coverage.)
- Occupational injury. 100% coverage is provided for those with occupational injury for medications, medical aids and nutritional supplements.
- Emphasized. 100% coverage, with a 300 HUF copayment for medications taken continuously or lifelong for chronic diseases or chronic prevention.
- Raised. Medications taken continuously or lifelong in chronic diseases and disorders, moderately severe chronic illnesses and for diseases which are severe, but require shorter medical treatment. Medications in this category can only be purchased with a valid medical indication certificate issued by a specialist. The extent of the coverage can either be 90, 70 or 50%.
- Full price. If patients with no social security coverage need prescription only medications, they can purchase them at full price.
What does the social security coverage category depend on?
Considering that a certain type of medication can be purchased under different prescription titles, the same type of medication can be purchased by different patients at different coverage categories (or even by the same patient by different medical indications).
The coverage category is determined by the patient’s current disease(s) and the current medical indication(s).
Who decides on the extent of the coverage?
Social security coverage can be applied on medications and special nutritional supplements with marketing authorization, if the NEAK has declared them to be eligible for coverage. During the determination process of the coverage category, the NEAK decides complying with the prevailing legal regulations.
During the process, besides the health politic principles, the NEAK considers the budget, the funding availability, controllability, predictability, transparency, and other aspects as well, complying with professional requirements and EU principles.
Who decides on the medications’ price?
In the price establishment of medication with no coverage the principles of the free competition prevail. There are no special regulations on price formation, pharmaceutical companies cannot influence the prices either. Therefore, pharmacies can freely decide on the prices of medications with no coverage, influenced only by the prevailing principles of the free competition, and supply and demand.
For medications with coverage, the price is determined by the pharmaceutical company. The NEAK decides on the medications’ health insurance coverage declaration and coverage category, after considering several health politics and cost effectiveness studies. After that, the pharmaceutical companies can determine the medications’ prices considering the abovementioned principals.
For medications with coverage, the NEAK performs a blind-bidding process for medications containing the same active agent with the same potency (generic drugs). Blind-bidding means that pharmaceutical companies as (market) operators propose (bid) prices to their own products without knowing the prices of other companies for their generic drugs. By this technique, the prices of commonly taken medications can be kept low. To summarize, the purpose of the blind-bidding is to decrease the prices of the generic drugs and thereby decreasing the NEAK’s expenses spent on medication coverage.
Public health coverage
Public health coverage offers additional financial support on medications with social security coverage in order to further decrease the copaymant fees. This public health coverage is determined at district offices, considering the budget for medication coverage.
In order to improve patients’ life quality, considering their severe condition, based on the principals of common social risk-bearing and equity, the National Health Insurance Fund of Hungary (NEAK) can offer individual coverage on medications, nutritional supplements and medical aids which normally would not be covered by social security insurance. The NEAK can also support rental or reparation fees of medical aids (or component changing fee of medical aids produced after individual size sampling). Coverage frequency and conditions on medical aids can vary.
For further information on individual coverage, medication-coverages, and the process for determining coverage categories, visit the NEAK’s website.