Are compounded drugs covered by insurance?

Are Compounded Drugs Covered by Insurance?

Patients and their caregivers experience confusion over what their insurance covers. This is particularly true when they are prescribed a compounded medication. The reality is that it depends on the insurance company. Some cover compounded prescriptions. Some cover compounded medicines under certain circumstances while others do not cover compounded drugs.

If a patient needs a special formulation or specific delivery method (such as a patch, liquid or dissolvable under the tongue) and their need for the compounded prescription is long-term, they need to contact their insurance company. Many cases are decided on a case-by-case basis.

Patients are often in a "Catch 22" situation where their medical condition necessitates special dosing methods so that they can take the medicines they need. For example, some patients can't swallow pills and need their medication crushed or liquefied.

Costs over the last five years have risen dramatically for compounded medications. Some suppliers have forced up the cost of bulk powders in the quest for increased profits.

A number of insurance plans cover compounded medications, but there are still restrictions that patients face. Some require that the compounding pharmacy be in-network. Others will require that you pay more for out-of-network providers. To further complicate the patients' dilemma, a pharmacy may be in-network for regular prescriptions and out-of-network for compound drugs.

And it can become even more complicated. For example, if one component in a compound medication is not on the insurance company's list of coverage list, it won't be covered. Compounding pharmacies try to accommodate patients' needs and their insurance coverage and will sometimes be able to remove the ingredient not covered (without affecting effectiveness) or by substituting an approved generically equivalent ingredient.

If a patient needs a compounded medication long-term, the prescribing physician can call the patient's insurance carrier for pre-approval. This is probably the most efficient way for patients to ensure that their medication will be covered by their insurance carrier.

In general, compounding pharmacies must be accredited for any insurance carrier to reimburse for compounded medications. Additionally, some carriers such as United Healthcare also require their individual credentialing for the pharmacy.

Many compounding pharmacies will also provide a Universal Claim Form with each prescription so that the patient can submit it to their insurance company for possible reimbursement.