A new fund is planned to help cover certain high-cost medicines through the Dominican Republic’s Family Health Insurance system. Here are 10 points to help you understand what has been approved, what is still pending and what employers and employees can do now.
1. The CNSS approved the fund
The National Social Security Council (CNSS) approved the creation of the Fondo de Medicamentos de Alto Costo, or FOMAC, through Resolution 645-16. The approval sets a framework for expanding access to selected high-cost medicines through the Family Health Insurance system (SFS).
Approval is an important step, but it does not mean the fund is already operating or that medicines are available through it today. Implementation details still matter.
2. The initial plan covers 13 medicines for 16 conditions
FOMAC is expected to provide 100% coverage for an initial catalogue of 13 medicines intended for 16 catastrophic diseases or conditions. Public information mentions certain cancers, autoimmune and rheumatological conditions, acromegaly and spinal muscular atrophy.
The full resolution and an official, detailed list of the medicines and covered conditions still need to be published. For that reason, it is best not to assume a particular medicine or diagnosis is included until the official details are available.
3. The proposed coverage is 100%, without copayments
For medicines included in the FOMAC catalogue, the plan provides for 100% coverage without copayments or moderating fees. This is intended to reduce the direct cost to eligible affiliates for those medicines.
That does not mean every high-cost medicine, treatment or related health service will automatically be covered. Coverage is tied to the fund’s catalogue and the medical criteria that will apply. The authorities are expected to clarify how those criteria work as implementation progresses.
4. Coverage is planned for both SFS regimes
The planned coverage applies to affiliates in both the contributory and subsidized regimes of the Family Health Insurance system. The contributory regime generally covers people with formal employment and their eligible dependents; the subsidized regime serves eligible people who are not covered through formal employment.
Your eligibility and the steps for accessing a medicine will depend on the final operating rules. Employees and families should look for guidance from the relevant authorities and health-system institutions once the process is formally established.
5. The fund is not expected to start immediately
The approval provides for a preparation and capitalization period of up to 12 months. During this time, the fund is expected to accumulate resources and prepare the operational arrangements needed to begin coverage and dispense medicines.
SISALRIL has said that FOMAC is expected to enter operation within a maximum of one year from formal CNSS approval. Until the authorities confirm that operations have begun, do not treat the approval date as the date coverage becomes available.
6. The planned funding comes through the SFS
The fund is expected to be financed through Family Health Insurance resources. Public announcements describe an increase of RD$50.64 in the monthly health capitation. The amount allocated per affiliate to support health coverage.
SISALRIL has stated that the arrangement is not expected to create additional deductions for workers or extraordinary contributions for employers. The exact funding mechanics and allocation should be confirmed through the formal implementation documents as they become available.
7. DAMAC is expected to manage the fund
FOMAC is planned to be managed by the Directorate of Access to High-Cost Medicines (DAMAC) within the Ministry of Public Health and Social Assistance. Resources are expected to be administered through a specialized account managed by the Treasury of Social Security (TSS).
This structure is intended to define how funds are managed and how the programme operates. The authorities are expected to publish further practical information about the processes for requesting, approving and dispensing medicines.
8. The catalogue will guide what is covered
FOMAC is designed around a defined initial catalogue, rather than general coverage of every high-cost medicine. This distinction is useful for employees and employers: a medicine’s high price alone does not confirm that it is included.
The official details will help clarify which medicines and conditions qualify, what medical documentation is required and where patients should go for support. Until then, avoid relying on unofficial medicine lists or assuming a treatment is approved under the fund.
9. Employers can prepare without changing benefits prematurely
Employers do not need to make immediate changes to their health benefits based only on the FOMAC approval. They can, however, keep employees informed and review how their existing group health plan is intended to work alongside public SFS coverage.
A group plan may have its own benefits, exclusions and claim procedures. FOMAC’s planned coverage should not be treated as a replacement for reviewing those terms. If you are considering your company’s coverage, you can explore Grupo RiskPro’s group health insurance service or review our insurance and risk management services.
10. Use official updates to confirm next steps
The most reliable way to understand FOMAC’s scope is to follow official information from the CNSS, SISALRIL and the Ministry of Public Health. Check for publication of the full resolution, the official medicine and condition details, eligibility criteria and instructions for accessing the benefit.
For a summary of the approval, read the Presidency’s announcement and SISALRIL’s information on the fund and its expected timeline.
How can a company prepare?
You can take three practical steps while the operating details are being developed:
- Review your current group health plan and identify how employees can ask questions about existing benefits.
- Clarify what is known and what is still pending. Share official updates without presenting the planned fund as an active benefit.
- Update your internal guidance when eligibility, medicine lists and access procedures are formally confirmed.
Clear information supports better decisions
FOMAC is expected to expand access to a defined group of high-cost medicines through the SFS. The approval sets out an important direction, while the detailed rules and operational start remain ahead.
If you are reviewing health coverage for your team, you can speak with an advisor about your current plan and the questions to revisit as official information develops. Contact Grupo RiskPro when you are ready to talk through your needs.
This article is for general informational purposes only. It does not constitute legal or medical advice. Confirm coverage, eligibility and treatment decisions with the relevant authorities and qualified professionals.