By: Brian Carpenter, R.Ph., Coventry
My colleagues that participate in CompPharma authored a very good piece on compounding medications.1 While the recommendations made by the consortium are sound, we need to apply practical steps given the current environment versus a retrospective response.
First Script, Coventry’s Pharmacy Benefit Management (PBM) program, manages to the NCPDP D.0 format andhas stringent pricing mechanisms in place for network pharmacies. That is a major reason 80% of the compound prescriptions are submitted out-of-network. Financially, compounding pharmacies do not wish to have their enormous margins eroded nor be susceptible to our auditing process.
Again, I am in complete agreement with the consortium’s recommendations. Simply, they lack any teeth. All of the recommendations are requests for action and do not prevent the dispensing of compounds. The work comp environment supports basically any medication even remotely related to the open claim to be payable. California knows this too well through their lien process.
So, some practical strategies that might garner a better return for our clients:
- Coventry is working directly with legislators to:
- Change compound billing practices and require a UR-type of process that supports claim examiners in denying these medications until required documentation is provided; i.e., letters of medical necessity, sighting legitimate compendia, or medical record evaluation for allergies to a specific oral medication.
- Define standards to ensure compounds are identified on ‘paper bills.’
- Define pricing mechanisms based on largest available quantities to individual ingredient components.
- Contract with clinically and financially responsible compounding entities for inclusion in the PBM or extended network.
- Coventry’s Regulatory and Legislative Affairs team works with states to supply actionable information. As this issue continues to grow, the rule-making bodies will need a clear idea of how to balance the support of the injured worker and the payor community.
My compliments to the CompPharma team for a well written piece. It balances injured workers’ needs and strives to aid in cost containment. We must work to change the course to have the right clinical and financial long-term impact.
Coventry WCS is a WorkCompWire Ad Partner.
This is not a paid placement.