ESI and CVS/Caremark Announce Plans to Curtail Compound Coverage
Express Scripts (ESI)
On June 3, Express Scripts launched its new “Compound Management Solution”
and began contacting its clients through sales force calls and a
national webcast on Tuesday, June 10. ESI’s “solution” to a growing
number of claims for compounded preparations is simple: they won’t pay
ESI’s clients – individual companies, insurance firms, unions,
self-insured businesses of all sizes – are being told that ESI has
created a list of excluded ingredients which ostensibly would only cover
those medications that the PBM deems “clinically acceptable and
reasonably priced.” What’s on that list? Nobody knows. Even ESI
admitted that the “list” isn’t yet available when directly questioned by
its clients. No information was provided that describes the process by
which clinically acceptability was determined. And, most importantly,
in statements made to clients, ESI alleges that participating in their
new “Compound Management Solution” will eliminate almost 95% of all
Clients are being told that they can implement this new “solution”
effective July 15 by notifying Express Scripts’ account management by July 3, 2014.
If the client does not respond at all, they will be automatically
enrolled in the “solution” effective September 15. Although most
clients already provide coverage with a prior authorization management
system, the new program will eliminate that entirely and drugs on the
so-called-to-be-determined-we-don’t-know-yet list will be automatically
rejected with a “Not Covered” rejection code.
“Rather than establishing a workable and logical ‘prescription benefit
management’ program for compounds, Express Scripts is taking the easy
way out and saying ‘just don’t pay for these’ medicines,” says IACP
President Pat Stephens, PharmD. “That is detrimental to patient health and,
given the ridiculously short notice and implementation timeline they’ve
proposed, it’s clear that the impact on patients wasn’t even addressed.”
On May 30, CVS/Caremark announced plans to their provider manual related to copayment collection and claims for compounds. Click here to see the copy of this announcement obtained by IACP.
As with many other PBMs and insurance plans, participating pharmacy
providers are expected to collect the full amount of the copayment from
the beneficiary – no discounts, no waivers, not “copay coupons” – unless
otherwise permitted by either Caremark or state law. PBMs are auditing
copayment collection documentation and it looks like Caremark may be
considering the same. Failure to collect the full copayment could lead
to termination of a pharmacy’s network contract.
While documentation of copayment collection is an important “must do” in
your pharmacy, Caremark is now requiring a completely different and
onerous type of documentation for any and all compounded preparations
submitted for reimbursement.
Effective immediately, compounders not only have to include the NDC
number of each ingredient use in the compound they must also have “at
least two (2) scientifically valid studies in peer-reviewed journals
supporting the clinical efficacy of the additional ingredients” for each
of those ingredients and have those studies available if Caremark
“This is nothing more than an administrative hurdle designed to deny
coverage for legitimate prescriptions and keep beneficiaries from
obtaining the medications they need,” says IACP Executive Vice President/CEO
David G. Miller, RPh. “It’s discrimination… pure and simple.” With an
estimated fifty percent of all prescription drugs used for extra-label
purposes, Caremark has an established track record of reimbursing for
medications for which no clinical studies exist. Yet, the PBM has not
nothing to address extra-label dispensing or reimbursement. Only
compounds are singled out.
Of particular concern to IACP is that the peer reviewed medical
literature on compounded preparations and their individual ingredients
is scant. While the IACP Foundation has supported research into some
ingredients and preparations – most notably BHRT – there are literally
thousands of APIs, inactive ingredients, bases, flavorings, dyes, etc.
for which studies have never been completed. Even the profession’s most
referenced peer-reviewed journal, the International Journal of
Pharmaceutical Compounding, doesn’t have the extent of information as
Caremark is requesting.