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受托人的意见
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在再保险
原告: 员工
被申请人: 雇主
ROD案例编号: 93-098 - 2007年5月23日
受托人: 迈克尔W. 巴克纳,. 弗兰克·邓纳姆，迈克尔·H. 荷兰,
艾略特一. 西格尔.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for name brand prescription drugs under the terms of the 雇主 Benefit Plan.
背景事实
1994年3月, 被申请人实施了一项处方药计划，要求使用仿制药代替品牌药. 以便获得品牌药品, the prescribing physician must submit written justification of the medical necessity for the brand name drug(s) to the 雇主’s Plan Administrator for approval. 代替医生的信，一个
1-800电话号码可供医生直接与计划管理员联系. The Respondent requires that the 员工 pay the difference between the cost of the generic and the brand name drug if the 员工 does not receive approval from the Plan Administrator. The Respondent states that 员工s were informed in writing and that 员工 meetings were held to explain the procedures to obtain brand name drugs under the Respondent’s drug program.
申诉人的医生为申诉人的高血压开出了品牌药Tenormin. The Complainant’s spouse had the prescription filled and was required to pay the difference between the cost of Tenormin and its generic equivalent. 心烦意乱的是，她不得不支付比共付额更多的钱来购买Tenormin, the Complainant’s spouse contacted the Respondent who advised her to obtain a statement of medical necessity for the brand name drug from the Complainant’s physician.
在六月二十三日致答辩人的信中, 1994, the Complainant’s physician indicated that the letter that he was providing addresses all of the physician’s patients who receive prescription drugs through the Respondent’s insurance carrier. 医生在处方上写着"医疗必需品牌"时就表明了这一点,他不希望处方上有替代药物. 这封信还解释了为什么医生对非专利药物总体不信任. 然而, 信中没有提及投诉人, 或使用Tenormin与通用等效物的原因. 申诉人说，这封信是他的医生向被投诉人提供的唯一答复.
被投诉人的计划管理人于7月6日致函投诉人, 1994, that the Complainant’s request for full benefits coverage for Tenormin was denied because the Complainant’s physician was unable to provide a specific medical reason as to why Tenormin was medically necessary.
争端
被告是否需要提供品牌药物Tenormin的全部福利?
双方立场
Position of the 原告: The Respondent is required to provide benefits for the brand name drug Tenormin because the Complainant’s physician wrote “brand medically necessary” on his prescription. 这位医生还提供了一般性的论据，说明为什么未经他的批准，仿制药不应该被替代.
Position of the 被申请人: The Respondent is not required to provide benefits for the brand name drug Tenormin because the Complainant was informed of the procedures to receive brand name drugs under the 雇主 Benefit Plan and the Complainant’s physician did not provide a specific medical rationale that explains why the generic equivalent of the brand name drug Tenormin should not be utilized.
相关的规定
第二十条(10)b款. 1993年《官方网站》规定:
第二十条——健康和退休福利
(10)保健:
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加强成本控制计划
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b. 仿制药替代
如果受益人在有仿制药的情况下使用品牌药, 受益人负责仿制药和品牌药之间的成本差异, 除了正常的共同支付. 一种仿制药除非得到联邦食品和药物管理局的批准，否则不会被认为是“可用的”. 除了, 如果开处方的医生确定使用品牌药是医学上必要的, 仿制药将不会被认为是“可用的”,并且受益人不会因使用品牌药而额外支付费用.
1993年雇主福利计划第三条导言的有关部分指出:
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, 或计划另有规定. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan. . . .
第三条. A. 1993年《官方网站》(4)(a)的有关部分规定:
第三条福利待遇
(4) 处方药
(a)提供的福利
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处方药或胰岛素的合理收费也包括在内. 合理收费包括:
(1)每份处方或补药实际开出的金额;
(二)适用的仿制替代药品价格, 如果是AB或更高评级, approved by the federal Food and Drug Administration; or, 如果开处方的医生确定使用品牌药物在医学上是必要的, the price of such brand name drug; or
(3)雇主设立的处方药项目向参与药店支付的现期价格.
然而, 在任何情况下，受益人均无责任为单一处方支付超过本计划中规定的适当共付额, 加上非专利药和品牌药之间的差价, 在适用情况下.
第三条A. (10) (b)及(h) 2. 1993年雇主福利计划的有关部分指出:
(10) 一般规定
(b)管理
计划管理人有权颁布实施和管理本计划的规章制度, 该等规章制度对与根据本计划领取福利的受益人打交道的所有人员均具有约束力. . . .
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(h)利益解释(EOB)和保持无害
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2. The 雇主 and the UMWA agree that excessive charges and escalating health costs are a joint problem requiring a mutual effort for solution. 在任何情况下，提供者试图收取过高的费用或对医疗上不必要的服务收取费用, 如计划所界定, 来自受益人, 计划管理人或其代理人应, 经受益人书面同意, 试着解决这个问题, 通过协商解决方案或为提供商发起的任何法律诉讼进行辩护. . . .
第四条. A. (2) 1993年雇主福利计划的相关部分指出:
第四条. 管理式医疗，成本控制
A. (2) 除了, 雇主可实施某些其他管理式医疗和成本控制规则, 哪些福利既适用于PPL提供者，也适用于非PPL来源, but which (except for the deductibles and co-payments specifically provided for in the Plan) will not result in a reduction of benefits or additional costs for covered services provided under the Plan.
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讨论
第二十条(10)b款. of the 1993 Coal Wage Agreement requires that a Beneficiary pay the difference in cost for the use of a brand name drug when the generic equivalent is available. If, 然而, 开处方的医生确定品牌药物在医学上是必要的, 通用等效物将不被认为是“可用的”,，受益人将不会额外付款. 第三条A. (4) (a) 2. of the 1993 雇主 Benefit Plan provides for the applicable generic substitution of brand name drugs if they are rated AB or better and have federal Food and Drug Administration approval. It also allows benefits for brand name drugs in those cases where 开处方的医生确定品牌药物在医学上是必要的.
第三条A. (10) (b)授权“计划管理人”颁布实施和管理“计划”的规章制度. The Trustees have determined in prior RODs (see RODs 81-697 and 84-042) that such rules and regulations are binding if they are reasonable and have been effectively communicated to the Beneficiaries. 此外，第四条A. (2)规定雇主可以实施其他管理式医疗和成本控制规则，但是, 计划中规定的免赔额和共同付款除外, 这些规则不能导致减少福利或增加计划所提供的服务的费用.
本案被告建立了一个仿制药替代计划，以帮助控制药品成本. 在这个项目下, 如果处方上的药是品牌药，而非专利药是可用的, 该计划将只支付通用价格减去适用的自付额和免赔额，受益人将支付差额. 被告表示，它通过邮件通知受益人收到品牌药品的要求，并召开了员工会议. Information sent to Beneficiaries by the Respondent informed them that they “[m]ust submit a letter from the physician indicating the reason why taking a Brand Name drug is a medical necessity.”
在ROD 93-079, the Trustees addressed the issue of whether an 雇主 can require a Beneficiary to provide medical documentation to support the use of brand name drugs. The Trustees determined that an “雇主’s requirement that physicians provide a statement to the Plan Administrator justifying the use of a brand name over a generic drug is reasonable and consistent with the provisions of the 1993 Coal Wage Agreement and the 1993 雇主 Benefit Plan; provided, 然而, 雇主不得强行制定规则，武断地阻碍或拒绝受益人合理、及时地获得所需药物. 在药品由受益人担保的销售点环境中, 规则不应该是不必要的繁琐或限制性的.“因此, 被投诉人可要求投诉人提供医疗文件，以证明使用品牌药品优于非专利药品的合理性.
答复被申请人关于处方品牌药品Tenormin的正当理由的请求, the Complainant’s physician submitted a letter stating that the letter addresses all of his patients who receive prescription drugs from the Respondent’s insurance carrier. 申诉人的医生在他的处方上写上" Brand medical required "时指出了这一点, 他不希望处方上有替代药物. 医生的信, 然而, 没有说明为什么医生给投诉人开了品牌药泰诺明而不是非专利药. 投诉人的医生没有提供足够的文件证明将泰诺明处方于非专利药之上, 被告不需要为品牌药物Tenormin提供全部福利.
受托人的意见
在没有证明医疗需要的文件的情况下, the Respondent is not required to provide benefits to the Complainant beyond those for a generic substitute drug for the brand name drug Tenormin, 符合1993年雇主福利计划的规定.