The Express Scripts’ Network Pharmacy Weekly (click here to view) of September 24, 2015 announced that effective October 1, 2015, the Tricare prescription benefit program they administer was expanding the exclusions list for compounded preparations. In addition to the already excluded APIs announced back in May, Express Scripts and Tricare are now excluding classes of solid dose forms as well. In other words, even manufactured drug products used in a compound will now be considered “non-covered.”
ESI did not provide a list of specific drugs. Instead, it published a very broad list of therapeutic classes as “exclusions” under which FDA-approved drug products could be rejected if they are used in a compound. Those classes include: acne, pain/inflammation, skin disorders, infertility, vitamins/minerals, enzyme deficiencies, endocrine disorders, and the “catch all” category labeled “miscellaneous conditions.”
“Clearly, despite statements that changes to the benefit design were to control escalating costs, it’s becoming apparent that Tricare and Express Scripts intend to completely eliminate coverage of compounded preparations. At first it was an elimination of Active Pharmaceutical Ingredients. Now it’s a refusal to pay for when a pharmacist uses a manufactured drug to create the compound prescribed by the Tricare beneficiary’s physician,” says David Miller, IACP executive vice president. “This new ‘by class’ exclusion initiative places pharmacists in an even more difficult position because we now have to make judgements about what is and isn’t covered, educate physicians and pharmacists, and either deny patients the medicines they need or accept non-payment for their services.”
ESI notes that non-covered products in these categories will cause compound claims to reject with 70 (Product/Service Not Covered), along with the Reject Field Occurrence Indicator in field 546-4F denoting the non-covered ingredient. If a pharmacy sees this rejection, they have three options: 1) switch to a covered ingredient with approval from the prescriber; 2) switch the patient to an FDA-approved non-compounded drug, or 3) resubmit the claim and accept non-payment for the non-covered ingredients.