Facts
The present case concerns the question of the extent to which the costs of treatment with the medication Imigran can be covered by mandatory health insurance. It is undisputed that Imigran, in the form of administration used here (6 mg ampoules), is listed in the Specialty List (LS) as a medication for migraine and that the listing does not include any limitation. The dispute therefore essentially concerns the question of whether, in the absence of a quantitative limitation for the purpose of economic control under Art. 73 HIO, it can be considered that the cost of treatment according to the dosage prescribed by the attending physician (up to 12 injections per day) must be covered, or whether, according to the legal position of the appellant and the Federal Office of Public Health (FOPH), the maximum dosage recommended by the manufacturer and approved by Swissmedic (2 injections per day) precludes a more extensive legal obligation to provide coverage.Considerations
According to case law, the legal ordinance (Art. 52 para. 1 let. b HIA; Art. 34 and 64 et seq. HIO; Art. 30 et seq. HIBO) generally excludes the coverage of the costs of medications that are not included in the exhaustive and binding Specialty List. In the ATF 130 V 532 judgment, the Federal Tribunal ruled that, in principle, only the medical indications examined and deemed admissible within the framework of the authorization procedure by Swissmedic can be covered by mandatory health insurance.
In the present case, it is not a matter of covering a medical indication not approved by Swissmedic, but of the costs resulting from the exceeding of the dosage recommended by the manufacturer and approved by Swissmedic. According to case law, the specific medical indication and the applied dosage are closely linked from the perspective of authorization and inclusion in the Specialty List. When the FOPH bases its assessment of the efficacy and appropriateness of a medication on the…