Medications Outside the Basket — Why This Is One of the Most Important Covers

One question that keeps coming up in health-insurance reviews is: "If I have Shaban and a private policy — will I get the medication?". The careful and accurate answer is: not always, and not in every situation. Medications not included in the public health basket can be expensive, and the medication cover in a private policy is one of the items that can make a major financial difference in a complex medical case. That said, it is a cover subject to terms, ceilings and exclusions that vary between policies.

What the public health basket is

The Israeli health basket is the list of services and medications that the state funds through the HMOs under the National Health Insurance Law. The basket is updated each year by the Ministry of Health's Basket Committee, on the basis of professional recommendations and the budget allocated for the update.

What "outside the basket" means

"Outside the basket" medications are medications not included in the basket in a given year — whether they have not yet entered, have entered only for a specific indication, or are registered in Israel but not included in the public basket. Advanced oncology, biological, gene-therapy and rare-disease medications are common examples, but the category is broader and changes over time.

Why some medications do not enter the basket immediately on approval

A medication that receives regulatory approval in Israel is not automatically added to the basket. It must pass through the Basket Committee, compete for a limited budget, and sometimes also demonstrate cost-effectiveness. As a result an approved medication may be available to private patients but not subsidised through the HMO — sometimes for years. In that situation cover through a private policy can be especially valuable.

What medication cover usually looks like in a private policy

• Coverage ceiling — the maximum amount per case and per period.
• Deductible — a fixed amount or percentage the insured pays of the medication's cost.
• Indemnity vs. lump-sum payment mechanism — actual-expense reimbursement vs. a defined cash payment.
• Waiting period — time from joining until the cover can be used.
• Required approvals — sometimes the insurer's medical committee must approve.
• Exclusions — pre-existing conditions, specific indications, or situations excluded in the policy.

What to check in a policy before relying on the cover

• What is the coverage ceiling per medication, per case and per period.
• What is the deductible — a fixed amount, a percentage, or a combination.
• Whether this is an indemnity or a lump-sum policy, and what that means for the payment mechanism.
• The waiting period and any exclusions related to a pre-existing condition.
• Whether the insurer's medical committee approval is required, and through what process.
• What the claim process looks like — required documents and expected processing times.
• Whether the policy distinguishes between medications registered in Israel and medications purchased abroad, and under what conditions.

Common mistakes

• Assuming the label "medications outside the basket" guarantees cover for every medication.
• Choosing the cheapest policy without comparing ceilings and exclusions.
• Cancelling an old policy with better terms without a review.
• Ignoring waiting periods — joining early while healthy is an advantage.
• Relying on a verbal explanation rather than on the written policy wording.

When to review the cover

The right time to review the cover is before a medical need arises, not after. After a diagnosis, most insurers will examine whether the situation was already known at the time of joining. A periodic review of the policy — every one to two years — keeps the cover aligned with the updated basket and with the family's situation.