PacificSource coverage for compounded medications is changing

9/15/2014 9:55:39 AM

From time to time, we make changes to our prescription drug benefits. In developing our medication coverage policies, it is our goal to provide access to medications with the best clinical results at the lowest costs. To support this goal, we will be changing how we cover compounded medications beginning October 15, 2014.

Most compounded medications are not reviewed by the Food and Drug Administration (FDA) for safety and efficacy. Our pharmacists and physicians work to ensure that our members are taking the safest and most effective medication. To this end, we will begin preferring FDA approved formulary medications over non-FDA approved, compounded medications.

Effective October 15, 2014, we will only cover compounds under the following circumstances:

  • All FDA approved medications have been tried and failed.
  • If all FDA approved medications have been tried and failed, then only compound ingredients that are covered on the applicable formulary will be reimbursed.
    • All compound ingredients must still be submitted on the adjudicated claim.
  • PacificSource Pharmacy Services Department has approved a new prior authorization since the implementation of this change.

We have sent similar letters to your patients who are impacted by this change. Please work with your patients to determine if an FDA approved, covered medication will be an appropriate alternative.

To review the applicable formularies for coverage, please visit our websites.

For questions or to initiate a prior authorization, please visit PacificSource.com/providers, or contact our Pharmacy Services team at:

  • Medicare and Medicaid: (888) 437-7728
  • Commercial: (844) 877-4803

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