Health insurance companies win dispute against pharmaceutical company

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Millions dispute over cholesterol lowering: Health insurance companies prevail in the federal social court

The Federal Social Court (BSG) has supported the position of the statutory health insurance companies and has confirmed that in the future only the fixed amount far below the actual selling price of the preparations will have to be reimbursed for the blood-lowering drug Sortis from the pharmaceutical manufacturer Pfizer. Patients of the statutory health insurance companies pay the rest out of their own pockets.

The US pharmaceutical company Pfizer is not impressed by the BSG's decision and declared that it wanted to stick to its price strategy for the cholesterol-lowering drug Sortis (atorvastatin). Price reductions are not planned because the group is still convinced that Sortis as a therapeutic innovation should not be tied to the fixed amount, a Pfizer spokesman said after the judgment of the BSG in Kassel (Az: B 1 KR 7/10 R and B 1 KR 10/10 R).

Fixed amounts for sortis cholesterol-lowering agents lawful The health insurers had included the sortis cholesterol-lowering agent in the fixed-amount group of HMG-CoA reductase inhibitors because of their lack of therapeutic superiority over other statins and reimbursed a correspondingly low fixed amount for the preparations. Health insurance patients who insisted on treatment with Sortis had to pay heavily. Between 28.30 euros (10 milligrams, 30 pieces) and 158.55 (40 milligrams, 100 pieces) per pack had to be brought out of the patient's own pocket. The BSG has now confirmed this position and classified the classification or reimbursement according to the fixed amounts of the pharmaceutical group of HMG-CoA reductase inhibitors as legal. This was a relief for the health insurance companies, as they faced additional billions in payments with higher remuneration for Sortis. However, the corresponding costs will continue to be borne by the patient in the future, as Pfizer is apparently not prepared to reduce the costs. Certain patient groups could benefit more from Sortis than from other statins, which clarifies the innovative performance of the preparation and justifies the much higher price, the company spokesman said after the judgment.

Pharmaceutical company and insured are suing through all instances The pharmaceutical company, together with a statutory health insurer who, according to its own judgment, relies on Sortis, had taken legal action against the fixed amount fixed by the statutory health insurance companies. As the last resort, the BSG in Kassel has rejected the complaint of the insured and the pharmaceutical company and confirmed the classification of the cholesterol lowering by the health insurance companies. Based on the current findings, none of the plaintiffs can demand that the fixed amounts be canceled, according to the BSG judgment. If there were a study situation that justified important therapeutic advice, restrictions or exclusions for the group formation, the judgment could have been different, the BSG explained. However, such a study situation was not available to the first Senate of the BSG for the judgment, so that the plaintiffs' reasoning could not be followed. The established fixed-income group does not limit the therapeutic options and there are sufficient medically necessary alternative prescriptions available, emphasized the BSG.

Pfizer demands higher prices for numerous preparations At Pfizer, pharmaceutical prices are far above the fixed amounts determined by the health insurance companies, which is by no means unusual. So far, legally insured patients have had to pay for the Pfizer products Accupro (Quinapril), Accuzide (Hydrochlorothiazide, Quinapril) and Selectol (Celiprolol).

The drug Sortis (atorvastatin) is a cholesterol synthesis inhibitor, also called CSE inhibitor for short. In conventional medicine, the drug is administered with a prescription to lower LDL cholesterol. The health insurance companies are of the opinion that the cholesterol-lowering drug Sortis will not be reimbursed at a fixed price due to the lack of therapeutic superiority over other agents. According to this judgment, patients who still insist on treatment with atorvastatin must continue to pay high additional payments. (fp)

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