€70.33

initial deductible / year

€636.12

annual cap

€2.50

per medicine after the cap

40/65/100%

reimbursement categories

Three stages within one year

A medicine year always follows the same shape. First you pay for prescriptions in full until the 70.33-euro deductible is met. After that Kela reimburses part of every purchase according to the category. Once your own share reaches 636.12 euros the annual cap is met, and for the rest of the year you pay only a 2.50-euro charge for each reimbursable medicine per purchase.

The deductible does not apply to anyone under 19: children and young people are reimbursed from the first purchase. The deductible starts to apply from the beginning of the year in which you turn 19. It also counts towards the annual cap, so it is not an extra cost but the first part of the cap.

The categories: 40, 65 or 100 per cent

Basic reimbursement applies automatically when a medicine is on Kela’s reimbursable list. Special reimbursement is a different matter: it requires a doctor’s B statement and a decision from Kela, and it covers specific conditions each with its own reimbursement number. The decision does not appear by itself — the doctor writes the statement, but submitting the application is usually left to the patient.

What you pay yourself under basic reimbursement

With basic reimbursement the cap is reached at around 1,013 euros of annual costs. Under the lower special rate it takes about 1,687 euros, because your own share is only 35%. Under the higher special rate the cap is rarely reached at all: at 4.50 euros a time it would take more than 140 purchases in a year.

Reference price: where you pay twice

Medicines with the same active substance form a reference price group, and Kela calculates the reimbursement from the group reference price — not from the price you actually pay at the pharmacy. If you choose the more expensive product without medical grounds for refusing substitution, the amount above the reference price is entirely yours. That is the first cost.

What does not count towards the cap

The cap builds up only from reimbursable medicines. Over-the-counter products, vitamins, most basic creams and anything Kela has not approved for reimbursement stay outside the calculation even when a doctor prescribed them. A private doctor’s fee has its own Kela reimbursement, and public healthcare client fees have their own annual cap — neither feeds into the medicine cap.

The cap is also personal. Family members’ costs do not combine: everyone has their own deductible and their own cap. In a household of three where all take prescription medicines, January brings 210.99 euros of deductibles in total. A child under 19 has no deductible, so a family with children ends up with a smaller sum.

Practical points at the pharmacy

• ·The reimbursement is deducted directly with the Kela card; there is nothing to claim separately.
• ·Information about reaching the cap reaches the pharmacy without any separate notification.
• ·At most three months’ worth of medicine can be bought at a time with reimbursement.
• ·Special reimbursement starts only after Kela’s decision — keep the receipts, since a retroactive claim can be made for six months.
• ·Over-the-counter medicines, vitamins and most basic creams are not reimbursed and do not count towards the cap.

If medicine costs fall early in the year and the deductible cannot be paid at once, it is worth asking Kela about a medicine credit. It lets the deductible be paid in instalments, and its use has grown noticeably. You can follow your own progress towards the cap in OmaKela in real time, which is worth doing if you take several medicines.