Breaking News! Second Largest Mass. insurer end coverage of Compounded Drugs

By The Associated Press June 13, 2013

BOSTON — The second largest health insurer in Massachusetts has announced that it will no longer cover specialty medications known as compounded drugs, months after a deadly nationwide meningitis outbreak was traced to a Massachusetts compounding pharmacy.

The chief medical officer at Harvard Pilgrim Health Care says the policy stems from a safety review after the meningitis outbreak traced to tainted steroids produced at New England Compounding Center in Framingham that killed 58.

Dr. Michael Sherman tells The Boston Globe that most of the insurance claims it received from patients for compounded drugs were for medications that should not be covered by a health insurer.

The coverage ends Aug. 7, but Harvard Pilgrim will consider appeals on a case by case basis.

The decision drew fire from pharmacists and patient advocates.

Blue Cross Blue Shield Position in Tennessee on Reimbursement for Compounds

COMPOUND DRUG INFORMATION

Compound drugs, which require a prescription from a doctor, are prepared by a pharmacist who mixes or adjusts drug ingredients to customize a medication to meet a patient’s individual needs. 

Differences Between Compound Drugs and Other Prescription Drugs

Compound drugs often have the same active ingredients as brand-name and generic prescription drugs but can differ from these medications in:

• strength – compound drugs can be prepared in strengths not usually available;
• inactive ingredients – compound drugs can be made without some of the dyes, sugars, preservatives and other inactive ingredients found in regular prescription drugs; or
• form – compound drugs can be prepared as lozenges or syrups instead of hard-to-swallow pills or in other forms that are not usually available..

Coverage for Compound Drugs
Check your Evidence of Coverage (EOC) or member handbook to see if your plan covers compound drugs.

If compound drugs are covered by your plan, it’s important to remember that pharmacies that are in-network for regular prescription drugs may be out-of-network for compound drugs. Based on your pharmacy plan, you may not have to pay 100 percent of the drug’s cost if the pharmacy is in-network for compound drug prescriptions.  Check your EOC or member handbook for more information on your plan's required copayment and/or deductible amounts.

You may have to pay more out of your pocket if you have a prescription for a compound drug filled at a pharmacy that is not in-network for compound drugs.  Check your EOC or member handbook for more information on your plan's coverage for compound drugs purchased at a non-participating pharmacy.

If you have mail order benefits, you can obtain your compound drugs from the mail facility and have your mediations shipped directly to you. 

Choosing a Compound Pharmacy

If you use compound drugs, make sure the pharmacy you use is in-network for filling compound drug prescriptions.  You can do this three different ways:

• Call the pharmacy you use and ask if they are in-network for compound drugs.
• Use our “Find a Pharmacy” tool.
• Call the Member Service number on your ID card.

How to Use the Online “Find a Pharmacy” Tool to Find a Compound Pharmacy:

• Select your Pharmacy Network.  It is listed on your BlueCross BlueShield of Tennessee ID card -- for example, RX01.
• Select the “Compound Pharmacy” option in the box underneath the Pharmacy Network field to make sure your search is for pharmacies in-network for compound drugs. 
• You may also enter your favorite pharmacy’s name, your city, state, zip code or county to narrow your search.
• Click the “Search” button once you have selected or entered all the appropriate information.

Remember -- Pharmacies that are in-network for regular prescription drugs may be out-of-network for compound drugs.  If you fill a prescription for a compound drug at a pharmacy that is not in-network for compound drugs, you may have to pay more out of your pocket for your medication.

Information is from here.

 

Dr. Loyd Allen's Editorial on Reimbursement Discrimination

In the current issue of Compounding Today, Dr. Loyd Allen makes some excellent points about reimbursement discrimination when it comes to FDA approved drugs versus compounded drugs.  For example, Dr. Allen states:

They will pay for compounded medications when the patient is in the hospital (intravenous admixtures, TPN solutions, oncology cocktails, etc.) but will not pay for medications from an independent pharmacy for the same patient. To make things even more conflicting, in some cases it is the same independent pharmacies that are preparing the medications for the hospitals due to drug shortages, etc.

 

To read the rest of Dr. Allen's comments click here. 

Correct coding of compound drugs for BCBST in Tennessee

Any legend drug altered from its manufactured form for use by a specific
patient is considered a compound. Since compounded medications do not have an
NDC number, specific HCPCS Level II codes may not be used. Eligible compound
drugs must be billed with the most appropriate HCPCS Level II unclassified/not otherwise classified code. An example of a compounded medication is bevacizumab (Avastin®) for intravitreal
injection.  Bevacizumab is supplied from   the manufacturer in 400 mg and 100 mg
vials with a concentration of 25 mg / mL. It is typically repackaged into single dose
syringes with a concentration of 1.25 mg /0.05 mL for intravitreal injection and must
be prepared under sterile conditions by a compounding pharmacy prior to ocular use.
Effective Aug. 1, 2012, for each date of service compound drugs are administered,
instilled, inserted, or implanted, a reasonable compounding fee will be
reimbursed for commercial and BlueAdvantage claims if the pharmacy
compounding fee is submitted on a separate line item billed with the appropriate HCPCS
code for Pharmacy compounding and dispensing services.  Billing guidelines for compound drugs can be reviewed in the billing and reimbursement section of the BlueCross
BlueShield of Tennessee Provider Administration Manual found online at
www.bcbst.com.

Article is found here.