From 1 April 2023, cannabis is no longer a narcotic. Patients can now get a regular prescription for the medicine they need. However, a prescription for cannabis does not mean that the cost of the medicine will be covered by health insurance. In the case of a cannabis prescription, insurance companies require patients to submit a claim for reimbursement in advance.
Since the change in the law in 2017, medical cannabis has been available as a prescription medicine. The medicinal plant, in the form of flowers but also extracts, oils and capsules, was previously tradable under the strict conditions of the Narcotic Drugs Act.
What steps are now necessary to ensure that the cost of medical cannabis is covered by statutory health insurance? Throughout this article, we will cover the details and requirements for filing a claim for cannabis flower reimbursement.
Firstly, a simpler but more expensive solution for the patient: if the doctor decides that cannabis is the medicine of choice in a particular case, he can issue a private prescription to the patient. This is independent of whether the patient has private or statutory insurance, as it is referred to as a self-pay prescription. The patient can then take the prescription to the pharmacy of their choice and pay the cost of the medicine out of their own pocket. Prescription cannabis requires the presence of a sufficiently serious medical condition, for more information see here in our detailed blog post on the subject.
Information for privately insured persons: Before submitting any prescription to a health insurance company, you should check with your health insurance company in advance to see if your private health insurance plan covers the cost of medical cannabis. Private health insurance companies make decisions independently of the actions of statutory health insurance companies and in many cases, the assumption of costs also depends on the rate group chosen in the private insurance plan.
Information for patients with statutory health insurance: Before the attending physician issues a prescription from the public health insurance (formerly a pink prescription) instead of a private prescription, a claim for reimbursement must be submitted to the relevant health insurance company.
The patient makes the request. In the next section you will learn when the statutory health insurance company will cover the costs, what documents are required and how long the whole process takes.
The German Social Code (Sozialgesetzbuch) regulates when a person is entitled to treatment with cannabinoids in the form of dried flowers or extracts in serious illness. Section 31(6) SGB V defines the following (1):
This applies if there is no generally accepted treatment available that meets medical standards, if they have already been exhausted, or if the treating physician cannot use them because of expected side effects.
In addition, they must have cannabis treatment a not insignificant chance of a noticeable positive effect on the course of the disease and/or symptoms of a serious illness.
In order for the cost of medical cannabis covered by statutory health insurance, the patient or their authorised representative must submit a request.
The application is then assessed by the health insurer or the health service it has appointed.
Eines der Hauptkriterien ist die Frage, ob keine allgemein anerkannte, dem medizinischen Standard entsprechende Leistung als Alternative zur Verfügung steht oder diese Optionen bereits ausgeschöpft wurden.
Um das beurteilen zu können, stellen die Krankenkassen einen Fragebogen bereit, den der behandelnde Arzt ausfüllt. Eine Vorlage für den Arztfragebogen stellt der Medizinische Bund auch auf seiner Website read.
Application form for assumption of costs for medical cannabis requires detailed information about the disease, current symptoms and what measures and medications have been used so far.
In many cases, the application is completed by the doctor together with the patient. The doctor then signs it and the patient or their legal representative then submits it to the health insurance company.
After receiving the application, the health insurer has three weeks to assess the application and inform the applicant of its decision. In most cases, the statutory health insurer will use the relevant medical cannabis service (MDK) to review applications. A decision can then take up to five weeks. If the time limits are not met, the application is deemed approved.
Palliative care with medical cannabis is a special case: because the patient must be treated as quickly as possible, the health insurance company must decide within three days whether to cover the costs.
If the medical service commissioned by the health insurer decides that the health insurer will not reimburse the patient for the cost of cannabis, the patient can appeal the decision. The decision will include a written reason why the costs will not be covered, which the patient should refer to in the appeal. The negative decision is often based on the fact that standard measures or available medicines have not yet been fully used. If necessary, it is advisable to seek advice from your doctor or lawyer.
As already mentioned, it is always possible for a doctor to prescribe cannabis on a private prescription. Without the consent of the statutory health insurer, the only option is a private prescription, which the patient pays for himself.
The statutory health insurance company only accepts prescriptions for reimbursement if they are pre-approved. This means that the pharmacy that fills the prescription can only submit it to the health insurer if it has a copy of the written authorization for reimbursement.
However, there is one exception: in order to make it easier, especially for pain patients, to obtain the necessary cannabis medicines without an approval process that takes several weeks, the German Pain Society (DGS) has launched a pilot project together with the AOK Rheinland/Hamburg (3) .
As part of this project, doctors have the opportunity to receive special training and certification. When these trained physicians prescribe cannabinoids, there is no need to seek cost approval. This approach is intended to reduce the bureaucratic burden and allow patients quicker access to medical cannabis.
This means that if cannabis is prescribed by a certified pain therapist, the statutory health insurer will waive the submitted claim and reimburse the cost without approval. Initially, this agreement was only made with AOK Rheinland/Hamburg, but in the future other health insurance companies have the possibility to join this agreement.
Patients with serious illness have the right to adequate treatment. In some cases, cannabis can be effectively used as a medicine and prescribed by the treating physician. However, whether the statutory health insurance company will cover the cost of treatment depends on a social medical assessment as part of the health insurance company's review of the claim. corporate medical service.
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