Festbeträgen

Festbeträge are fixed reimbursement amounts used in the German statutory health insurance system (GKV) for a subset of prescription medicines. They were introduced to control rising drug costs and to steer pricing through market competition among manufacturers. The concept applies to medicines that are grouped into fixed-amount categories, rather than being reimbursed solely based on the actual price of the product.

Legal basis and administration: The fixed-amount scheme is established by regulations under the German Social Code Book V (SGB V), notably the Festbetragsverordnung. The groups and the corresponding fixed amounts are defined and periodically updated by the relevant authorities, with input from the Federal Joint Committee and the National Association of Statutory Health Insurance Funds. The fixed amounts are published in an official list (Festbetragsliste or equivalent) that pharmacies and prescribers use to determine reimbursement.

How it works for patients and providers: Medicines that fall within a Festbetrag group are reimbursed up to the specified fixed amount for that group. If the medicine’s price is at or below the Festbetrag, the insurer covers the price (subject to the usual patient co-payments). If the price exceeds the Festbetrag, the insurer pays only up to the fixed amount, and the patient may have to pay the difference, in addition to the standard co-payment rules. Pharmacists may prefer prescribing medicines within the Festbetrag when clinically appropriate, to minimize patient out-of-pocket costs.

Scope and exceptions: Festbeträge cover many, but not all, prescription medicines. There are mechanisms for medically justified exceptions or deviations under certain circumstances, allowing physicians to prescribe outside the Festbetrag when necessary and with appropriate authorization. The system is periodically revised to reflect market changes and therapeutic developments.