Compounded Medications

What are compounded medications?

Compounded medications are those made to order by a pharmacy to meet the specific needs of an individual patient when existing, commercially available medications are inadequate or unavailable. Patients may need a compounded medication for a variety of reasons, including when they have an allergy to a specific inactive ingredient or need a liquid formulation due to trouble swallowing when only a tablet or capsule is available.

Are compounded medications covered?

Insurance coverage for compounded medications depends on the ingredients used. The active ingredients in the compound must be covered by your plan, which is outlined in your formulary (see below). Compounded medications may be subject to medical necessity criteria or limitations, including dosage and cost. Examples of when a compound is not covered include:

Compound contains any ingredient excluded by the benefit (e.g., contains over-the-counter medications, are used for cosmetic purposes [ex. scars])
Product is not medically necessary
Topical compounds containing products not FDA approved for topical use (e.g., ketamine, gabapentin, tramadol…)
Compound is from an FDA outsourcing facility

All compounded medications will be billed as Tier 2 medications up to $200, meaning you are responsible for your Tier 2 copay plus any costs over $200. For example, if you are a student and get a compounded medication that is $250, you would be responsible for the $30 Tier 2 copay plus the $50 over $200, making your total out of pocket cost $80. If you are a student and get a medication that is $130, you would just be responsible for the $30 Tier 2 copay. Most compounded medications are under $200.

Find your Tier 2 copay in your formulary:

Where can I get compounded medications?

Reliant Compounded Solutions in Southport, CT is Yale Health’s preferred compounding pharmacy and is the only compounding pharmacy that can directly bill Yale Health. Most compounding pharmacies don’t bill any insurance companies.

If you decide to use any other compounding pharmacy, you will have to pay for the full cost of the medication up front and submit for reimbursement. The reimbursement claim will be reviewed according to your plan’s terms and conditions.

How do I submit for reimbursement for compounded medications?

If you pick up a compounded medication from a pharmacy other than Reliant, or Reliant was unable to bill us for that medication, you can submit for reimbursement through Prime Therapeutics either electronically or via mail.

To submit a claim electronically, follow these steps:

Go to Prime Therapeutics and log in or make an account.
At the top of the page, select Tools and Resources > Forms and Information > Prescription Drug Claim Form.
Fill out the form and be sure to include all the request information as well as upload a copy of the receipt from the pharmacy that includes the cost of each ingredient in the compound.
If you are unable to submit an electronic claim, you can submit a paper Pharmacy Claim Form via mail.