In the latest trend of compound coverage and reimbursement, certain payors have begun requesting medical and scientific evidence directly from physicians prescribing compounds, as part of their determination as to whether a given prescription should be covered.
For some time, certain PBMs have “required” two peer reviewed studies from the billing pharmacy for every ingredient contained within the compound. Conversely, other PBMs have been calling doctors urging them to prescribe a non-compounded medication or otherwise providing them information about the cost of the prescription. Now, it appears that certain payors have started combining the two tactics and are now asking doctors directly (as opposed to the pharmacies) to provide peer reviewed information and other evidence of safety and efficacy, directly to the payor for the compounds they prescribe. This phenomenon is particularly alarming as prescribing physicians often rely heavily on the pharmacy’s unique formulations and suggestions when prescribing medications, and may not be equipped to adequately respond to these questions.
Pharmacies providing suggested formulations to physicians need to be prepared to explain the underlying reasons for the suggested formulation and to assist physicians in providing this information. If a pharmacy relies on a sales force, the marketing representatives should be instructed on how to explain compounds to referring physicians, and, potentially, provide literature that physicians may use as a reference.
If physicians cannot adequately justify the compounds that they are prescribing, this presents not only payment/coverage issues, but also a professional liability issue, implicating the physician and the pharmacy. For that reason, pharmacies working collaboratively with prescribers must be prepared to fully explain and document the scientific and medical rationale for the medications that are prescribed. Contact Frier Levitt for help navigating your pharmacy through the evolving regulatory requirements and avoiding potential liability.
