Effective on August 7, 2013, Harvard Pilgrim will no longer provide coverage for compounded prescription medications for members age 18 and older.
This decision is based on safety and cost considerations. As you know, compounded drugs are not approved by the U.S. Food and Drug Administration (FDA). This means that the FDA does not verify the safety and effectiveness of compounded drugs and that compounded drugs lack the FDA’s finding of manufacturing quality. Additionally, the cost of these drugs isn’t adequately controlled.
This change does not apply to members under age 18 because compounding is sometimes necessary to make certain medications appropriate for children. In most instances, compounding for this age group consists of making an FDA-approved prescription medication more palatable for kids, for example converting a pill into a smaller, easier-to-swallow capsule or altering the dose.
If you are currently prescribing a compounded drug for a Harvard Pilgrim adult member, it is likely that our comprehensive, open formulary includes an FDA-approved medication that can treat your patient’s condition. If one of these covered, FDA-approved medications is prescribed, the member is responsible for the copayment as determined by that person’s benefit plan.
However, if the member continues to use a compounded drug, the individual will be responsible for paying the full cost of the medication, with payment made directly to the pharmacy.
If you believe that there are no other available treatment options for your Harvard Pilgrim patient, you may submit an exception request on their behalf. Exceptions requests should be submitted to:
Harvard Pilgrim Pharmacy Services
93 Worcester Street; 4 East
Wellesley, MA 02481
Please include the following:
- Member Name
- HPHC ID#
- Diagnosis being treated
- Compound being requested (list of all ingredients)
- Quantity being requested
- Length of treatment
- Compounding pharmacy being used
- Other prescription medications tried to treat this condition
- Other information that may be helpful in considering coverage