Anthem Blue Cross dropping coverage for certain prescription compounded drugs

Kevin Knauss

9 years ago

Certain compound drugs will no longer be covered

Anthem Blue Cross of California

September 1, 2015

Starting November 4, 2015, Anthem’s prescription drug plans will no longer pay for certain compound drugs that contain ingredients not approved by the Food and Drug Administration (FDA). A compound drug is a customized medication prepared by a pharmacist for a specific person. Some of your clients may be affected by this change, if they are taking one of these drugs, particularly ones containing:

Compounded bulk powders (not FDA-approved)
Pharmaceutical adjuvants(this could be a binding agent, suspension or any ingredient used to modify the compound, and not FDA-approved)

For a compound drug to be covered by one of our plans, it must contain only FDA-approved ingredients (with some exceptions for ingredients essential to compound administration). A prescription is also required for the drug. These control measures are in place to protect our members and to help make sure compound drugs are safe and effective to use.

We will continue to cover compound drugs with ingredients that are FDA-approved and not otherwise excluded, as defined under the plan.

How we will notify impacted members
We’ll let our impacted members know about this change 60 days in advance. The next time they fill a prescription for one of these drugs, they may have to pay the full cost for it. They can talk to their doctors to find out if there’s another covered drug that would work as well for them.

Here’s a sample of the letter (see below) members will receive.

Applies to California individual and family plans (under 65), small groups, and large groups

Sample member letter

<DATE>

Starting November 4, 2015 certain compound drug(s) will no longer be paid by your plan.

Dear <Member First Name> <Member Last Name>:

During a recent review of drug claims it has come to our attention that we have been paying for certain compounded drugs that are not covered under your existing benefit plan. You recently filled a prescription for one or more of these compound drugs:

<RX #> , <date filled>, <Dispensing Pharmacy>

The compound drug(s) noted above is not covered under your existing drug benefit because one or more of the prescription ingredients within the compound is not approved by the Food and Drug Administration (FDA).

For a compound drug to be covered by your health plan it must contain only FDA approved ingredients and requires a prescription. Without FDA approved ingredients, we cannot be assured that the compound is safe and effective to use.

What does this mean to you?

Starting November 4, 2015, your prescription drug plan will no longer pay for the compound drug(s) listed above. That means, the next time you fill a prescription for any of them, you will have to pay the full cost of the drug. Please speak to your doctor to see if there is another drug(s) that is covered and proven to be safe and effective. For full details about your prescription drug coverage, please see your prescription drug rider or portion of your benefit plan that talks about drug coverage.

If you have questions or concerns, please call the customer service number on your member ID card.

We apologize for any inconvenience. We are committed to making sure safe and effective medications are available for you.

Anthem Blue Cross