Since 01.04.2023, cannabis is no longer a narcotic. Patients can now obtain a regular prescription for the medicine they need. However, a prescription for cannabis does not mean that the health insurance fund will cover the cost of the medicine. For cannabis prescriptions, the insurance companies require patients to submit an application for cost coverage in advance.
Since the change in the law in 2017, medicinal cannabis has been available as a medicine on narcotics prescriptions. The medicinal plant, both in flower form, but also as extracts, oils and in capsule form, was previously marketable under the strict conditions of the Narcotics Act.
What steps are now necessary for the costs of medicinal cannabis to be covered by statutory health insurance? In the course of this article, we will go into the details and requirements for the application for cost coverage for cannabis flowers
Firstly, the simpler but more expensive solution for the patient: if the doctor decides that cannabis is the medicine of choice in a particular patient case, he can issue the patient with a private prescription. This is independent of whether the patient has private or statutory insurance, as this is referred to as a self-payer 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. The prescription of cannabis on prescription requires the existence of a sufficiently serious illness, Find out more here in our detailed Blog article on this topic.
Information for privately insured persons: Whether your private health insurance plan covers the costs of medical cannabis should be enquired about in advance with the health insurance company before prescriptions are submitted to the health insurance company. The private health insurance companies decide independently of the procedure of the statutory health insurance companies and in many cases the assumption of costs also depends on the selected tariff group in the private insurance.
Information for patients with statutory health insurance: Before the treating doctor can issue a public health insurance prescription (previously a pink prescription) instead of a private prescription, an application must be made to the relevant health insurance fund for the costs to be covered.
The patient submits an application for this. You can find out in the next section when the statutory health insurance fund will cover the costs, which documents are required and how long the process takes.
When is a person entitled to treatment with cannabinoids, in the form of dried flowers or extracts, in the case of a serious illness is regulated in the German Social Code. Section 31 (6) SGB V defines the following (1):
This is the case if there is no generally recognised treatment available that meets medical standards, if these have already been exhausted or if they cannot be used by the attending physician due to expected side effects.
In addition, the use of the Cannabis therapy there is a not entirely remote prospect of a noticeable positive effect on the course of the disease and/or the symptoms of the serious illness.
So that the costs for medicinal cannabis are covered by statutory health insurance, the patient or their authorised representative must submit an application for this.
The application is then assessed by the health insurance fund or the medical service commissioned by it.
The Federal Medical Service provides a Assessment instructions for the socio-medical assessment of cannabinoids in accordance with Section 31 (6) SGB V ready (2).
One of the main criteria is whether there is no generally recognised alternative service that meets medical standards or whether these options have already been exhausted.
In order to be able to assess this, the health insurance companies provide a questionnaire that the treating doctor fills out. The Medical Association also provides a template for the doctor's questionnaire on its Website ready.
The application form for the assumption of costs for medical cannabis asks for detailed information about the illness, the existing symptoms and which measures and medication have been used so far.
In many cases, the doctor fills out the application together with the patient. The doctor then signs it and the patient or their legal representative then submits it to the health insurance company.
Once the application has been received by the health insurance company, it has three weeks to review the application and inform the applicant of its decision. In most cases, the statutory health insurance fund uses the competent medical service of the health insurance funds (MDK) to review cannabis applications. It can then take up to five weeks for a decision to be made. If the deadlines are not met, the application is deemed to have been approved.
Palliative care with medicinal cannabis is a special case: because the patient needs to be treated as quickly as possible, the health insurance company must decide whether to cover the costs within three days.
If the medical service commissioned by the health insurance company decides that the health insurance company will not cover the costs of cannabis for the patient, the patient can lodge an appeal against the decision. The decision contains a written explanation of why the costs will not be covered, which the patient should address in the appeal. A negative decision is often based on the fact that the standard measures or medication available have not yet been fully utilised. In this case, it is advisable to seek advice from your doctor or legal expert if necessary.
As already mentioned, the doctor can do this in any case, Cannabis on a private prescription to prescribe. Without authorisation from the statutory health insurance fund, a private prescription that the patient pays for themselves is the only option.
The statutory health insurance fund only accepts prescriptions for reimbursement if they have been authorised in advance. This means that the pharmacy that fills the prescription can only submit it to the health insurance fund if it has a copy of the written authorisation to cover the costs.
However, there is one exception: to make it easier for pain patients in particular to obtain the cannabis medicines they need without a multi-week authorisation process, a Initiative of 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. Prescriptions for cannabinoids by these trained doctors do not require a cost authorisation application. This approach is intended to minimise the bureaucratic burden and give patients faster access to medicinal cannabis.
This means that with a Cannabis prescription by a certified pain therapist the statutory health insurance fund waives the application presented and covers the costs without authorisation. Initially, this agreement was only concluded with AOK Rheinland/Hamburg, but other health insurance funds have the option of joining this agreement in the future.
Patients with a serious illness have the right to adequate treatment. Cannabis can be used effectively as a medicine in some cases and can be prescribed by the treating physicians. However, whether the statutory health insurance fund will cover the costs of treatment depends on the socio-medical assessment carried out by the medical service of the health insurance fund as part of the application assessment.
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