Drugs Outside the Basket: What Does Insurance Cover?

A vital drug that is not in the State's drug basket: this is one of the reasons why many people in Israel take out private health insurance. But what exactly does drug insurance cover? Here are the rules, to read before you sign.

What drug insurance covers

Drug insurance funds drugs that save or prolong life and that are not included in the health basket. It can also cover a drug that is in the basket, but for a different illness from yours (this is called an off-label prescription). The insurance supervisor (the Capital Markets Authority) requires policies to cover at least three cases:

Recognised countries

For the first case, three conditions must all be met: the drug is not in the basket, it has a medical indication for your condition, and it is approved for that condition in a recognised country. The list: Israel, the United States, Canada, Australia, New Zealand, Switzerland, Norway, Iceland, the countries that were members of the European Union before May 2004, and the countries of the European Medicines Agency's centralised procedure.

Why it is not paying twice

The supplementary insurance of your health fund (shaban, the fund's supplementary health plan) is not allowed to offer funding for vital or life-prolonging drugs outside the basket for a given insured person. Taking out this insurance with a private company therefore does not create a significant risk of double insurance.

Easier to obtain than from the health fund?

In most cases, the health fund requires proof that the drug is effective. Insurance companies have more flexible requirements, such as a publication in a recognised journal according to the terms of the contract. According to Kol Zchut, it is therefore most often easier to obtain funding for a drug through private insurance. If your cover stops and medical follow-up shows that the drug is helping you, you can then try to obtain continued funding from your health fund's exceptions committee.

Limits to be aware of

What is generally not covered

Experimental drugs (unless cover is bought separately), products related to dentistry, fertility, pregnancy complications or childbirth, cosmetic surgery, complementary or preventive medicine, food supplements, anti-ageing or weight-loss drugs, medical cannabis, and treatments related to an act of war or terrorism. Drugs used during an operation or a transplant are covered by operations or transplants insurance, not by drug insurance. Orphan drugs (rare diseases) are not covered by every company, and some policies exclude a drug that has an equivalent alternative in the basket.

Each company has its own list of drugs and its own level of reimbursement. Compare contracts line by line. As a French-speaking insurance broker in Israel, I do it for you, in French. Call me on 054 307 0916 or fill in the form below.