This article was translated from the original human-written German version. While we strive for accuracy, we cannot guarantee it is error-free. We recommend consulting the German original for the most precise information. This content is for informational purposes only and does not constitute financial or legal advice. Always consult with a qualified professional before making insurance or financial decisions.

Medications and Co-payments: The Detailed Service Comparison of GKV and PKV

In the German healthcare system, the provision of medications is a central pillar of health care. The crucial question of who bears which costs depends largely on the health insurance system: the Statutory Health Insurance (GKV) and Private Health Insurance (PKV). Insured individuals in both systems encounter different regulations that can significantly influence access to necessary therapies and the financial burden.

This article highlights the fundamental principles of cost coverage and explains the specific regulations for medications and co-payments in both GKV and PKV.

The Fundamental Differences: Solidarity Principle (GKV) vs. Equivalence Principle (PKV)

The German healthcare system is based on two main pillars, the GKV and the PKV, each pursuing fundamentally different principles.

Statutory Health Insurance (GKV) The GKV operates according to the solidarity principle. Contributions are income-dependent, and the scope of benefits is uniformly defined by law in the Social Code Book V (SGB V) as "sufficient, appropriate, and economical care" for everyone. The Joint Federal Committee examines whether new medical procedures are covered. Benefits can be adjusted by the legislator. Financing is done through a pay-as-you-go system without the formation of old-age reserves.

Private Health Insurance (PKV) The PKV, on the other hand, follows the equivalence principle and the funded system. Contributions depend on the chosen tariff, entry age, and health status. Insured individuals build up old-age reserves with their contributions. Benefits are individually contractually defined and cannot be unilaterally reduced by the insurer.

Medications and Co-payments in GKV: The Efficiency Requirement

In the GKV, the coverage of costs for medications and other services is strictly subject to the efficiency requirement according to § 12 SGB V.

For medicines and bandages, GKV insured individuals generally make a statutory co-payment. This is 10% of the price, but at least 5 Euros and at most 10 Euros per package. If the price of a medication exceeds the established fixed amount, additional costs may arise for insured individuals.

Medical Aids and Appliances: A co-payment of 10% (minimum 5 Euros, maximum 10 Euros) also applies here. The entitlement includes only the medically necessary standard version.

To protect against financial overload, there is an annual burden limit: all statutory co-payments are limited to a maximum of 2% of the household's annual gross income (1% for severely chronically ill individuals). The remuneration of contract physicians in the GKV is also carried out within the framework of budgetary regulations, which strongly influence a practice's economic planning.

Medications and Co-payments in PKV: Individual Tariff Benefits

In the PKV, the coverage of costs for medications and other services depends on the individually chosen tariff. The benefits are contractually defined and cannot be unilaterally reduced by the insurer.

Reimbursement is made in the contractually agreed amount. Depending on the tariff, benefits may also be covered that go beyond the GKV framework, such as:

More comprehensive reimbursements for eyeglasses and dental prosthetics (including implants).
Coverage for alternative medical treatments (e.g., naturopaths).

The billing of medical services in the PKV takes place directly between the doctor and the patient based on the scale of fees for physicians (GOÄ). Since there is no budgeting as in the GKV system, there can be differences in the freedom of medical therapy and prescription. The cost reimbursement principle is common in the PKV, meaning that insured individuals initially pay bills themselves and then submit them for reimbursement.

Premium Development in the Context of Medication Costs

The costs of medications and medical services influence premium development in both insurance systems.

GKV Premium Dynamics In the GKV, the premium is income-dependent. It increases with income (up to the contribution assessment ceiling of €66,150 for 2025) and with adjustments to the health fund's individual additional contribution.

PKV Premium Dynamics In the PKV, premium adjustments are legally regulated. They react to factors such as rising treatment costs, increased life expectancy, or changes in medical services. A portion of the premium is used to build up old-age reserves to cushion age-related cost increases.

Recommendations for Action

Choosing the right system requires a precise examination of individual needs.

For GKV Insured Individuals:

Inform yourself about the exact scope of benefits of your health insurance fund and use the co-payment exemption option if you reach the burden limit.
If necessary, consider private supplementary insurance to individually supplement statutory coverage for areas such as dental prosthetics or alternative therapies.

For PKV Insured Individuals:

Examine your tariff in detail for the included benefits and reimbursement rates for medications and aids.
In case of costly therapies, always clarify the cost coverage with your insurer in advance.
If necessary, use the statutory tariff change right to adapt your insurance coverage to your needs.

Summary

The coverage of costs for medications is fundamentally regulated differently in GKV and PKV. While the GKV offers legally defined basic care with regulated co-payments and a burden limit, the PKV, through its individual tariff design, enables more flexible and potentially comprehensive insurance coverage, with benefits contractually defined. For insured individuals in both systems, it is essential to know the specific characteristics of their coverage to ensure optimal and economical care.

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