Can your health insurer force you to use a generic brand of a medicine without your consent?

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Can your health insurer force you to use a generic brand of a medicine without your consent?

My husband has been taking Suboxone to aid in his sobriety for over 5 years. Last year his insurance company decided they were going to only fill the generic brand subutex and it really messed with my husband. He started becoming uncomfortable and feeling like he needed to take

more and more just to survive his day. He has now been off the generic brand and back on the name brand after his pharmacist fighting for him for 5-6 months and is still experiencing adverse affects. Do we have a case? I really do not want my husband relapsing or this happening to another person.

Asked on November 30, 2017 under Insurance Law, New Hampshire

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 3 years ago | Contributor

The health insurer can put limitations on what it will pay for in order to save money or reduce costs: e.g. that generics will be used instead of name brands. That is legal. Remember: generics are approved for the use by the FDA and should have minimal (if any) differences with name brands. They can be prescribed for the same exact things. Since the FDA regards them as equivalent, the insurer can say it will only pay for the less expensive one: that is not interfering with the medical care, because the generic may be used for the same treatment and conditions. Further, the insurer could not force your husband to use the generic against his will: he had the right to get the name brand and pay out of pocket for it. All they did was say that IF you want the insurer to pay, it must be the generic version; that is legal.


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