The change in the law in March 2017 has opened up the possibility of cost coverage and thus made cannabinoid therapy possible for many patients in the first place.
Patients with statutory health insurance must submit an application to their health insurer for the costs to be covered. Some health insurance companies provide their insured patients with the appropriate forms.
To ensure that the costs are covered, the application must be submitted before the first prescription is dispensed and the patient must wait until the first prescription is dispensed before the costs are covered.
The most important part of the reimbursement request is the written justification from the prescribing physician stating that the legal requirements for reimbursement of cannabinoid therapy are met. Patients are therefore dependent on the support of their physician.
Since the amendment to the law of March 2017 came into force, the possibility of assuming the costs of therapy with medicinal cannabis arises from Section 31 (6) SGB V:
Insured persons with a serious illness are entitled to a supply of cannabis in the form of dried flowers or extracts in standardized quality and to a supply of medicinal products containing the active ingredients dronabinol or nabilone if.
1. a generally recognized service corresponding to the medical standard
a) is not available or
b) in the individual case, according to the justified assessment of the treating contract physician, weighing the expected side effects and taking into account the medical condition of the insured person, cannot be used,
2. there is a not entirely remote prospect of a noticeable positive effect on the course of the disease or on serious symptoms.
When prescribed for the first time for an insured person, the service requires the approval of the health insurance fund, which can only be refused in justified exceptional cases, and which must be granted before the service is started. […]
In order for the costs to be covered by the health insurance fund, the prescribing physician must demonstrate that the medical conditions required in accordance with Section 31 (6) of the German Social Code, Book V are met:
Tip: The written justification can be strengthened if it is accompanied by specialist literature. If required, we will be happy to provide specific articles or studies.
According to the German Social Code Book V, an illness is considered serious if it is life-threatening or if the quality of life is permanently impaired due to the severity of the health problems it causes.
If the physician arrives at the reasoned assessment that the risks and side effects of a particular standard therapy are not reasonable for the patient given the patient’s state of health, then the patient need not have tried that therapy.
It is critical that the physician justify the non-use of each standard therapy.
If it is unclear which are the standard therapies for a particular indication that are expected by the respective health insurer, the health insurer should be asked to name them specifically so that it can take a position in each case.
According to § 13 para. 3a SGB V, the health insurance fund must generally decide on the application for cost coverage within three weeks.
If the health insurance fund decides to obtain an expert opinion (usually from the Medical Service of the Health Insurance Funds), the deadline is five weeks.
If cannabis therapy is to be provided as part of specialized outpatient palliative care (SAPV according to § 37 b SGB V), the approval period is three days.
If the prescription is to be made immediately following a, or during an inpatient hospitalization performed cannabis therapy.
If the health insurance fund does not reach a decision within the respective statutory period, the application is considered approved (§ 13 para. 3a SGB V).
According to Section 31 (6) of the German Social Code, Book V, the statutory health insurance funds may only refuse to cover costs in justified exceptional cases. This is an expression of the physician’s freedom of therapy.
Frequent reasons for refusal:
An appeal against the rejection of an application for cost coverage can be lodged within 1 month.
The grounds for appeal should be prepared in close consultation with the physician and should address the reasons listed in the rejection.
If the appeal is rejected, the patient has the right to take legal action in the social courts. In certain cases, such lawsuits are supported by the Arbeitsgemeinschaft Cannabis als Medizin e. V. (Cannabis as Medicine Association). Patients can obtain further information free of charge from the hotline of the Arbeitsgemeinschaft Cannabis als Medizin at www.arbeitsgemeinschaft-cannabis-medizin.de 0800 0226622.
Subsequent prescriptions can be made without reapplying for reimbursement. This also applies to adjustments of the prescribed quantity as well as changes between flower varieties or extracts.
When switching between extracts and medicinal cannabis flowers, many health insurers still consider a new application to be necessary. If a change in the form of therapy is planned, the patient should clarify this individually with his health insurance company as early as possible.
Note: If the health insurance company is changed, a new application for cost coverage must be submitted!
A private prescription without cost coverage for both private patients – and for patients with statutory insurance may be issued at any time if the medical conditions are met.
In principle, private health insurance companies also cover the costs of medically necessary and medically prescribed drugs within the scope of the respective tariff.
Private patients who are to be treated with medicinal cannabis should contact their health insurance company before starting therapy to find out whether the costs will be covered.