Whether you have compounded medications or commercially manufactured medications, we’ve all experienced the shock of showing up at the drug store to pick up a prescription, only to find out insurance doesn’t cover it. It would be hard to discuss the thousands of insurance plans in this article, but we’ll try to give you some guidance on insurance coverage for compounded medications.
Here’s on insurance coverage for compounded medications
Some insurance plans cover all compounded medications, others only cover certain active ingredients, and some do not cover compounded medications at all. You can check with your plan provider to see if the all the ingredients in your compounded prescription are covered, but most pharmacies bill insurance carriers online, and can quickly determine if the prescribed medication is covered.
We wish we could give you a clear list of insurance coverage for you – Tricare covers this and Aetna covers that, but insurance coverage is quite complex. Here are a few tips that may help.
- Many plans cover compounded medications only if a commercially available tablet is crushed and used to make the compound. Unfortunately, because of the additives and dosages in the tablets it is not always possible to use a crushed tablet when making a compound.
- Some group health plans cover compounded medications, but require a Prior Authorization to be completed by your physician stating why this therapy is needed. (See information below on Prior Authorizations.)
- For Medicare patients, the optional Part D plan pays for prescription drugs. Part D only covers the ingredients that are FDA-approved. For a suspension, they may cover the tablets that will be crushed and used, but not the syrup or flavoring that creates the liquid suspension.
- If you are at present not covered by Tricare, some ingredients are covered but there may be limits on how much you can receive, and Tricare may require your physician to complete a Prior Authorization request for the medication.
- Even if your insurance does cover compounded medications, the co-pay often falls in the highest tier. In these instances it may be cheaper to purchase a 3 month’s supply of medication out of pocket.
As you can see, it gets complicated! Make sure your compounding pharmacy will work with you and your physician to offer an affordable option for your compounded medication.
Prior Authorization demystified.
The pharmacy calls to tell you your medication requires a Prior Authorization, but you just need your medication. What does ‘prior authorization’ mean anyway?
This is how the process goes…
- The pharmacy processes a prescription claim online and receives a rejection message stating a Prior Authorization (or Prior Auth as we call it) is required.
- The pharmacy notifies the physician of this requirement. The physician completes the necessary insurance forms to state why this drug is needed and what other drugs have already been tried.
- The physician files the form with the insurance company for their review.
- Once this form is filed with the insurance company, they will review it and determine if they will authorize or approve coverage for the medication.
- If the Prior Auth is approved, the patient and physician are notified. The pharmacy is NOT notified; we have to place a follow up call to the insurance company to find out if it’s been approved. If so, then the pharmacy can proceed with preparing the medication.
Other important things to know about Prior Auths…
- Prior Auths are not specific to compounded medications. They are also required for many commercially manufactured drugs used to treat Multiple Sclerosis, Hepatitis, Rheumatoid Arthritis, Cancer and many other illnesses.
- Prior Authorizations are only in place for a specified time frame, so the review process must occur each time the Prior Auth expires.
- The Prior Auth process can take up to 2 weeks
- In our practice we see a very low approval rate for Prior Authorizations. However, we’ve noticed that the rate of approval goes up when patients are vocal with their insurance company about their need for the medication.
One last observation about insurance coverage for compounded medication, when calculating the cost of therapy, consider all aspects of therapy and not just the drug costs. If your elderly mother is having difficulty swallowing tablets and often goes without taking her medication, it may be worth paying out of pocket to have a liquid made for her. What are the ramifications associated with missed doses or non-compliance?
As you can see the subject of insurance coverage gets complicated! The Compounding Center cannot guarantee that your compounded medication will be covered by your insurance, but we can guarantee that we will work with you and your physician to find the best medication for your specific situation.
Call (855) 633-6948