Sometimes policyholders receive a different medicine from their pharmacy than they are used to. That medicine therefore has the same active ingredient, but it is from a different manufacturer and looks different. This is usually due to the health insurer’s preference policy. The Health Insurance Disputes Commission has clarified the policy of preference in recent judgments. This was reported by the Health Insurance Complaints and Disputes Foundation (SKGZ).
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The basic rule is: an insured person is entitled to mutually replaceable registered medicines designated by the minister. The preference policy defined by law is the only restriction allowed in this regard.
Clarification on the implementation of the statutory preference policy
A health insurer may designate one or more medicines with a specific active substance as a preference. In this regard, the following aspects are important:
- Is the use of a favorite medicine not medically justified for the insured person? Then it is up to the prescriber (eg the GP) to explain the ‘medical need’.
- Does the pharmacist have doubts about the explanation given? The latter should then contact the prescriber.
- If they cannot reach an agreement together, the pharmacist must demonstrate, on the basis of his professional knowledge, why the treatment with the preferred medicine is medically justified for the insured person.
- The Guide to Responsible Medication Change can be used for this.
Information obligation on the part of the health insurer
Does a health insurer have a preferential policy? In this case, these policyholders must inform them in good time via the policy conditions and the website.
Edited by: National Care Guide
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