A low monthly premium may seem like good news until a medical bill arrives. To calculate the annual co-payment for your basic insurance in Switzerland, it's not enough to look at the deductible: you also need to count the 10% share and, if applicable, the contribution for hospital stay. Separating these amounts from the premium avoids misleading comparisons and allows you to plan your budget more confidently.

In Swiss compulsory health insurance, the rules for cost-sharing are defined by law. What changes between people is the deductible chosen, the actual use of medical benefits and the type of treatment needed. The premium is paid every month, even if you don't use the insurance. The co-payment, on the other hand, appears when you receive covered benefits.

What's included in the annual copay

The annual co-payment is not a single fixed amount. For an adult, it is usually made up of three elements: the deductible, the 10% fee on subsequent costs and the daily contribution in the event of hospitalisation.

The deductible is the part of the covered medical expenses that you pay first during the calendar year. For basic insurance, the ordinary deductible for adults is CHF 300. You can also choose a higher deductible, up to CHF 2,500, in exchange for a lower monthly premium.

Once the franchise is exhausted, you bear 10% of the remaining costs, commonly known as own share. For adults, this share is limited to CHF 700 per calendar year. In other words, even if covered medical expenses continue to increase, 10% cannot exceed that annual limit.

If you are admitted to hospital, a contribution of CHF 15 per day is usually added. This contribution does not apply, for example, to maternity benefits or to minors. It may vary depending on your personal situation, so it is advisable to review the bill and the conditions applicable to your case.

The monthly premium is not part of the co-pay, but it is part of your total insurance cost. It's an essential distinction: a policy with a lower premium can mean a high deductible and therefore a higher expense if you need medical care during the year.

Formula for calculating the annual co-payment

The practical way to estimate the amount is simple:

Annual co-payment = deductible used + 10% of subsequent costs, up to the legal limit + hospital contribution, if applicable.

The deductible used will never exceed your chosen deductible or the covered expenses you have incurred. Then 10% is calculated on the part that exceeds that excess. Finally, the days of hospitalization subject to contribution are added.

Imagine you have a CHF 300 deductible and you generate CHF 5,000 of covered medical costs during the year, without hospital admission. First you pay CHF 300 in excess. There are CHF 4,700 left. 10% of that amount is CHF 470. Your annual co-payment would be CHF 770.

Now you take the same medical expense, but with a deductible of CHF 2,500. You would pay CHF 2,500 first. On the remaining CHF 2,500, 10% add up to CHF 250. The co-payment would be CHF 2,750. The premium for this option may be lower, but the monthly savings would have to make up for a considerable difference if you plan for frequent treatments.

In a year with very high expenses, an adult with a CHF 2,500 deductible can pay up to CHF 3,200 between deductible and 10% share. To this can be added the daily contribution for hospitalization. With the ordinary deductible of CHF 300, the maximum of these two components is normally CHF 1,000, before counting the hospital.

Expenses that should not be confused with the co-payment

The calculation only works for treatments recognised by basic insurance. If a benefit is not covered, you may have to pay for it in full. In this case, it is not the statutory 10% share, but an additional expense outside of the cover.

This can happen with certain dental treatments, unrecognised alternative medicine benefits, a private or semi-private room without supplementary insurance, or services billed outside the conditions of basic cover. The costs of transport, medicines and therapies also depend on whether they are prescribed, included in the cover and managed according to the applicable rules.

A distinction must also be made between basic insurance and complementary coverage. Each supplementary insurance may have its own deductibles, limits, waiting periods or participations. It is not advisable to automatically add its rules to those of the compulsory insurance.

How to Choose a Franchise with an Annual Vision

The deductible shouldn't be chosen just because it lowers the premium. The right decision depends on how much you think you're going to use the healthcare system and how much you could pay without pressure if an unexpected bill comes up.

A high deductible usually makes sense for someone who rarely needs medical care and maintains a sufficient financial reserve. But it is not a guarantee of savings. An injury, an operation, or a prolonged medical follow-up can change the outcome within a few months.

A low deductible costs more in premiums, but limits the amount you pay directly for covered benefits sooner. This may be a reasonable option if you already know you'll have regular treatments, expensive medications, or specialized checkups. For families, the analysis should be done per person: the deductible and participation limit are applied individually, not as a common bag for the whole household.

Children have their own rules. Their ordinary deductible is CHF 0 and can be raised up to CHF 600 to reduce the premium. In addition, the annual limit of the 10% share is CHF 350. If there are several children, calculating each case separately helps to prevent a family pension from appearing lower than it actually may be.

An example for planning your real budget

To make a useful decision, calculate two different figures. The first is the fixed annual cost: monthly premium multiplied by 12. The second is the possible variable cost: deductible, 10% participation and, if applicable, hospitalization. Then look at both scenarios together.

Suppose a person pays CHF 340 per month with a high deductible. Its fixed annual cost is CHF 4,080. If you have high medical expenses during the year, you could add up to CHF 3,200 in deductible and participation, plus a possible hospital contribution. Your total cost will be very different from what you would have in a year with hardly any consultations.

This comparison is not intended to predict a disease. It serves to answer a more specific question: Can I afford the maximum copay of my current option without destabilizing my finances? If the answer is no, a slightly higher premium may provide more predictability.

Data to review before making the calculation

To make the estimate reliable, confirm your current deductible, your medical expenses already billed for the year, and any outstanding benefits. Also check whether you have accident coverage included or excluded, as this can affect which insurer handles a claim. If you work at least eight hours a week for an employer, workers' compensation insurance is usually covered by the employer and not basic insurance.

The insurance model also matters for the care journey, although it does not change the rules of franchise and participation by itself. In family doctor, HMO or telemedicine models, following the agreed channel helps the treatment to be processed correctly. A bill derived from care outside the model can generate doubts or costs that do not fit into your initial forecast.

An independent platform like Lamalux® allows you to visualize premiums, franchises and models based on verifiable data, without sponsored rankings or automatic transfer of your data to intermediaries. The decision is still yours: comparing should give you clarity, not activate commercial pressure.

Annual copay FAQs

Does the CHF 700 limit include the excess?

No. For adults, CHF 700 corresponds to the annual maximum of the 10% share. The deductible is paid in advance and is added to that amount. Therefore, with a deductible of CHF 2,500, the usual maximum between the two is CHF 3,200.

Does the monthly premium count as a copay?

No. The premium is the fixed amount you pay to keep coverage. The copayment refers to the portion of covered health expenses you take on when you use benefits.

Does the calculation reset every year?

Yes. The deductible and participation limit apply per calendar year, from January to December. Amounts paid in one year do not reduce the deductible for the following year.

Before you change your deductible or model, keep a simple figure: the maximum co-pay you could bear and the medical expenses you already know you'll have. That reference turns a complex decision into an informed choice, based on your needs and not on isolated savings promises.