Conditions for health insurance to pay for medicines that patients buy themselves

Legal Consulting Department of Lao Dong Newspaper answers:

Article 59 of Decree No. 188/2025/ND-CP detailing and guiding the implementation of a number of articles of the Law on Health Insurance stipulates the conditions for paying costs directly to patients in cases where patients self-purchase medicines and medical equipment as follows:

At the time of prescribing, prescribing drugs, and prescribing the use of medical equipment, all conditions according to the following regulations must be met:

1. At the time the patient is prescribed or indicated, the medical examination and treatment facility does not have available medicines or medical equipment as prescribed in point b, clause 2, Article 43 of this Decree and falls into the case specified below:

a) For drugs: there are no commercial drugs containing active ingredients that are prescribed to patients or the same active ingredient but different concentrations or contents or forms or dosage and cannot be replaced for prescription for patients;

b) For medical equipment: there is no medical equipment that the patient is prescribed to use and no medical equipment to replace.

2. Cannot transfer the patient to another medical examination and treatment facility in one of the following cases:

a) The health status and pathology of the patient are determined to be not sufficient for transfer;

b) Medical examination and treatment facilities where patients are being examined and treated and are undergoing medical isolation according to the provisions of law on prevention and control of infectious diseases;

c) The medical examination and treatment facility where the patient is being examined and treated is a specialized medical examination and treatment facility or the highest level of technical expertise in the province or centrally-run city.

3. It is impossible to transfer drugs and medical equipment between medical examination and treatment facilities.

4. Medicines and medical equipment prescribed and indicated for use must be consistent with the scope of expertise of the medical examination and treatment facility.

5. Drugs and medical equipment prescribed and indicated for use must be within the scope of the rights of health insurance participants and have been paid for health insurance medical examination and treatment costs at one of the medical examination and treatment facilities nationwide.

6. Medical examination and treatment facilities are responsible for providing a receipt confirming the shortage of drugs and medical equipment according to Form No. 11 of the Appendix issued with this Decree to patients as a basis for payment.

Thus, patients who self-purchase medicines and medical equipment are directly reimbursed by health insurance when meeting the above conditions.

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