Patients and caregivers sometimes experience confusion over whether or not their insurance company covers their medication. This experience is particularly true compounded medications are prescribed. And, there is no easy answer. The long and short of the issue is this… it depends on your insurance company. Of course, that’s not the answer anyone wants to hear, but unfortunately, it’s the truth.

Reading the Insurance Company Tea Leaves

Some insurance companies cover compounded medications. Some cover compounded prescriptions so long as certain conditions are met or under very particular circumstances. Then, other insurance companies simply won;t cover them at all, leaving customers with name brand and generic base formulations as their only option unless they want to pay out of pocket.

So what do you do if traditional medication forms are not an option? Contact your insurance company and explain your situation if you need a specific formulation or particular delivery method (like a liquid, patch or melt tab). Also, if you are expected to take your medicine long term they need to understand that as well. Many of these cases are determined on a case by case basis. You may be able to make headway by doing that. It demonstrates you are taking control of your situation and you look responsible calling in to get to the bottom of the situation.

Out of Pocket Compounded Medicine Frustrations

We realize paying out of pocket can be frustrating. There is often a catch 22 scenario where patients are only able to take their medicine in a particular form (powder, liquid or cream) but are unable to do so because compounded medicine costs too much. Why is that the case?

Over the past few years, the cost for making compounded medication has increased substantially. Supplier forced the cost of bulk powders to go up, in search of more profit. Those expenses ultimately pass through the process and are handed down to the consumer in the form of a price increase. This reality can be painful if the customer is paying out of pocket. It;s not uncommon for sticker shock to set in once a cash price quote is given if a consumer is without insurance.

Understanding Compounded Medication Coverage Issues

The good news is a number of insurance companies have plans that will cover compounded medications. They still require the pharmacy to be in network. They may still cover an out of network pharmacy and simply require you to pay a bit more. The issue occurs when an insurance company determines a pharmacy is in network for regular medications and out of network for compounded prescriptions.

However, it can be even more convoluted. Let’s say your pharmacy is considered in network for both traditional and compounded medicine. However, when you submit your prescription you are told your compounded medicine is not covered even though it should be.

Here’s what’s going on. If your compounded medicine contains five ingredients and one is not covered under your insurance company, they will reject the entire medication for drug coverage. So, it’s very important to be clear before you submit your prescription. You may want to call your insurance company after you receive a compounded prescription and make sure all bases are covered just to be safe.

Coverage Assistance for Compounded Prescriptions

Also, understand compounding pharmacies are very familiar with these scenarios and try to accommodate customer’s needs. Sometimes they may be able to remove the ingredient in question. Other timer they might call your physician and see if the non-covered ingredient can be switched for one that is covered by your insurance plan.

Finally, your doctor may be able to call your insurance company and speak with them on your behalf if you need the medication long term. This is called pre-approval. Sometimes your compounding pharmacy can help in this regard too. They may need a Universal Claim from your insurance provider. Once it’s filled out and submitted, your compounded medicine is given a green light for approval.

Determining whether or not your compounded medication is covered by your insurance is usually multi-faceted. It requires communication with your insurer, and may even involve dialogue with your doctor and pharmacy. If you have any questions about your drug coverage, feel free to contact us. We will do our best to answer any questions you may have about your medicine. Our goal is to provide real people, like you, with real solutions every day.

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