Woodland Hills Pharmacy is offering universal claims forms to patients. As any patient who has been prescribed a compounded medication understands, getting coverage for prescriptions can be difficult. Insurance companies continue to deny reimbursement for compounded medications that patients need. Woodland Hills Pharmacy hopes that by offering the universal claims forms for compounded medications, more patients will be able to obtain reimbursement through their insurance company. The universal claims form will contain all the information needed for patients to submit requests for reimbursement to their insurance company. The items on the universal claim form will include the patient’s information, the medication information including NDC numbers, and the prescriber’s information.
FDA Approval and Insurance
Most insurance plans will only cover drugs that are FDA-approved. Compounded drugs are exempt from the requirements of FDA-approved drugs. Each one is made for an individual patient, and every formulation can be unique. The long, intensive process of FDA approval does not make sense for compounded medications. Since insurance companies only cover FDA-approved medications, most compounded medications are not covered.
Many times, however, compounded medications include components that are FDA-approved. For example, let’s say an FDA-approved tablet is made into an oral solution by a compounding pharmacist. The portion of the formulation made up of the tablet may be covered by insurance. The parts of a compounded medication that include FDA-approved drug products are the ones that may be given the OK for reimbursement.
One common example of this is the FDA-approved drug naltrexone. The FDA-approved naltrexone is prescribed in 50mg doses to help opioid addicts recover. At a lower dose of 1.5-4.5mg, the same drug is prescribed to treat a wide range of conditions including inflammatory bowel diseases, fibromyalgia, and arthritis. There is no FDA-approved formulation of naltrexone at a 4.5mg dose. However, a compounding pharmacy can make naltrexone at this dose using FDA-approved ingredients. While it is not guaranteed, it is more likely that this kind of compounded formulation will be covered.
Example of Universal Claims Form
The document shown here is an example of what patients can request when they receive a compounded prescription from our pharmacy. The information given is for sample purposes only and does not necessarily reflect the information that will actually be on an individual’s prescription.
Insurance Coverage of Compounded Medications: Looking Forward
While some patients may get reimbursed based on the criteria described above, others may have their compounded prescription denied regardless of the ingredients. More doctors are seeing the value in choosing to work with compounding pharmacies to customize treatments for their patients. Patients appreciate the relationship they develop with their compounding pharmacy, as they generally offer more personalized service than a retail chain pharmacy. The hope is that health insurance companies will change their policies to allow more compounded prescriptions to be covered. In the meantime, the team at Woodland Hills Pharmacy hopes some patients will be helped by having a standardized form for requesting reimbursement.