Drugs Outside the Health Basket: What Private Insurance Covers, How Much You Pay, and What to Do First

When a doctor prescribes a drug that isn't included in the health basket (סל הבריאות), there are usually three possible routes: your health fund (the basket and the shaban — supplementary insurance), the fund's exceptions committee (ועדת חריגים), and your private insurance. Private coverage is subject to conditions, a copay and a cap — and all of them are written in your policy, not on the company's marketing page. In this article we'll explain the order to work in, what a medication policy usually covers, how much you actually pay, and how to check the clause in your own policy.

What counts as a "drug outside the basket"

The health basket determines which drugs are publicly funded — and every drug in the basket also has an indication: the medical condition for which it is funded. So "outside the basket" usually covers two situations:

• A drug that isn't in the basket at all — for example, a new drug that hasn't yet entered the basket.
• A drug that is in the basket, but for a different indication — the drug is funded for a certain disease, but was prescribed to you for a condition not included in the indication (a use known as off-label). Many medication policies cover this situation too.

Important to know: since 2008, the health funds' shaban (שב"ן) plans have not been allowed to fund life-extending or life-saving drugs that aren't in the basket. Precisely because of that, for the truly expensive drugs, private insurance is usually the main route that remains.

The order of steps: health fund, exceptions committee, private insurance

Before paying out of pocket or filing a claim, it's worth going through the routes in order:

1. Check with your health fund. First make sure the drug really isn't available to you through the basket — sometimes it's in the basket for your indication and the problem is only an internal approval. Then check the shaban (your health fund's supplementary insurance), which covers some drugs that aren't in the basket, subject to the restriction on life-extending drugs.
2. The exceptions committee. If there's no regular entitlement, you can ask the fund for exceptional funding through its exceptions committee. The committee reviews individual cases, and if a fund approved a treatment for one member under certain circumstances — it must do the same in identical cases. A refusal can be appealed, including to the labor court.
3. Private insurance. If you have a medication policy (standalone or as part of health insurance), check the coverage terms and file a claim. Some policies cover regardless of the public route, and some require exhausting your health fund rights first — it's written in the policy.

The routes don't conflict with each other: you can open a request to the exceptions committee and, in parallel, check with the insurance company what a claim requires — so you don't lose precious time.

What a medication policy usually covers — and what it doesn't

In most policies, a drug is covered if it isn't in the basket for your medical condition, provided it's approved for use in one of the recognized countries the policy lists (usually Israel, the US, Canada, Australia, major European countries, or central approval by the European Medicines Agency). A prescription from a specialist is usually required, sometimes with a renewal every few months.

On the other hand, almost all policies exclude experimental drugs, dietary supplements, cosmetic treatments and other groups listed in the exclusions. One encouraging point worth noting: many medication policies have no waiting period (תקופת אכשרה), meaning coverage usually starts as soon as the insurance begins — but check that in the policy itself too.

How much you pay: the copay and when it's waived

The medication copay is usually monthly, in one of two forms: a percentage of the drug's price (typically 5% to 15%) or a fixed amount per month of treatment. Some policies also have a cap on the copay — a maximum monthly amount you'll pay, even if the percentage comes out higher.

The most important mechanism for expensive drugs: in some policies the copay is waived entirely once the drug's monthly cost passes a threshold set in the policy — in some policies this is on the order of a few thousand shekels a month. Some policies also exempt certain drug groups upfront, such as oncology treatments. How do copays work in the rest of the coverages? We covered that in more depth in the article on copays in health insurance.

The coverage cap: how much, for what, and when it renews

Every medication policy has a coverage cap — the maximum amount the company will pay. In many policies it's on the order of one to three million NIS, but the range is wide and the terms vary. It's important to understand not just the number, but how it's defined:

• What the cap applies to — the whole insurance period, an insured event, or a separate cap per drug.
• When it renews — in some policies the cap renews after a number of years fixed in the policy, and in others it's one-time for the whole insurance period.
• Sub-caps — for example, a monthly cap per drug, or a separate cap for certain indications.

In a long, expensive course of treatment, the difference between a renewing cap and a one-time cap can be the most significant difference in the policy.

How to check this in your own policy

The practical answers are found in two places: the medications chapter in the full policy wording, and the disclosure form (גילוי נאות) table, which consolidates, for each coverage, the insured amount, the copay and the caps. Look for the name of the coverage (for example "drugs not included in the health services basket") and check: the eligibility conditions, the copay amount, the waiver threshold, the cap and how it renews.

If the wording is convoluted, or the clauses contradict what you were told — it’s worth checking against the full policy wording. And when you reach the claim-filing stage itself — we have a separate guide on how to file a health insurance claim.

How Ravit can help

The answers relevant to you are in the policy itself. Send Ravit your policy documents on WhatsApp, ask in plain language, and get an answer based on your policy with a reference to the relevant clause — and when there’s no certainty, Ravit says so honestly instead of guessing.

The information in this article is general only and does not constitute medical, insurance, legal, or pension advice, and is not a substitute for reading your policy terms or consulting a licensed professional. Coverage, amounts, and conditions vary between policies and change over time — always verify against your own specific policy and an authorized professional.