Trimix is a compounded medication that combines alprostadil (PGE-1), papaverine, and phentolamine. The combination of these three ingredients is unavailable in a commercially available injection from drug manufacturers.
Trimix must be obtained from a compounding pharmacy that is equipped and proficient in sterile compounding, according to strict standards set by the United States Pharmacopeia (USP). This compounded medication is made from bulk drug powders, which may affect its coverage by insurers.
Most insurance companies do not pay for compounded medications that are made from bulk drug powders. There are several other factors that can affect whether an insurer will cover a medication or not. Read on for further details.
Understanding Medical Necessity In Health Insurance
One factor that affects whether an insurance company will cover a medication is whether that prescription is for a medical necessity. Unfortunately, the definition of “medical necessity” can vary from insurer to insurer.
One aspect that may affect a prescription being covered for a medical necessity is if the medication is used to treat a specific medical condition. An insurance company may decide not to cover a prescription based on the diagnosis or whether the medication is approved to treat that diagnosis.
While compounded medications are commonly used by prescribers, they are not FDA-approved to treat any diseases, which may result in a denied insurance claim. Other elements that may be considered to determine medical necessity are if the drug is used for convenience only, the drug’s place in medical guidelines, or medication cost. Contact your insurance company for more details on how they define a medical necessity.1
Patient Eligibility For Insurance Coverage Of Trimix
There are numerous factors that may influence a patient’s eligibility to get a prescription for Trimix covered by their insurance company, as was discussed above. This varies from company to company, so the only way to be sure that your prescription will be covered is to reach out to a representative from the insurance company to discuss what is included in their formulary.
Furthermore, it is important to find out the steps you can take if you do find out that the insurance company will not cover your prescription.
There may be certain exceptions and exclusions to coverage for prescriptions depending on patient age, history, prior drug therapy, medical history, or other factors.
Even if Trimix is covered by your insurance company, you may need to meet a deductible, may have a copayment, could have reached your coverage limit, or be in the coverage gap. Follow up with your insurance company to find out if these situations apply to your insurance plan.
Does Insurance Cover Trimix For Certain Medical Conditions?
It is important to know that while compounded medications have been used “off label” for many years to help certain medical conditions and are regulated by strict standards of quality, they are not FDA approved to treat any disease or condition. This may affect whether the insurance company will cover Trimix or not.
Does My Insurance Company Cover Trimix?
There are many different insurance companies in the marketplace, including Aetna, Cigna, Blue Cross Blue Shield, United Healthcare, Medicare, and others. Coverage varies between them, and by the individual plans that are offered within a particular insurance company.
Furthermore, as discussed above, there are also certain exceptions and exclusions within the plans themselves. The only way to know if your plan will cover this medication is to reach out to the customer service department of your insurance company, either by phone or online.
What To Do If Your Insurance Does Not Cover Trimix
If your insurance company denies your claim, there are still other steps you can take to try to get Trimix covered. The first step to take is to contact your insurance company and find out why it was denied. There may be a simple change that your doctor can make to the prescription or a procedure that must be followed to obtain coverage.
Depending on what the insurance company requires, the next step may be to contact your prescriber. Sometimes the insurance company requires prior authorization. A prior authorization involves the prescriber filling out paperwork explaining the need for the medication and may involve documenting prior drug therapy.
The insurance company may require you to submit additional paperwork in order to evaluate if Trimix will be covered. The pharmacy can provide you with a form that gives the insurance more detailed information about the medication that you can send to the insurance company to try to get your prescription covered. If you need these forms sent to you, our experienced staff will be happy to assist you.
If the insurance company still denies your claim after appealing the decision, there are still other ways to pay for your Trimix prescription. One option is to check coverage at an alternative insurance company. Contact other insurance companies to see if their coverage includes compounded medications like Trimix and if they will cover your other medications.
If there are no options to have your Trimix prescription covered, Medivera Compounding Pharmacy offers Trimix at a very affordable price for self-pay patients. There is even a discount for first-time prescriptions so you can see how the medication works for you.
You Can Balance Health With Financial Considerations
As you can see, there are many options available to pay for your Trimix prescription. Although your insurance company may not pay for Trimix, Medivera Compounding Pharmacy can direct you through the appeals process and offer an affordable price for cash-pay patients. Just because your insurance company does not pay for your prescription does not mean that you cannot find a way to fit it into your budget.
Lastly, when looking for a pharmacy to fill your Trimix prescription, make sure to use a pharmacy that is committed to high standards. Medivera Compounding Pharmacy has been compounding medications for more than 25 years. We are PCAB-accredited in sterile and non-sterile compounding, which is the highest standard in the industry. We make it a priority to give the highest quality medications to our patients. Reach out to us today for more information on how to fill your Trimix prescription.
Discover a personalized approach at Medivera Compounding Pharmacy. Take the next step with our specialized Trimix formulations.
References
- https://content.naic.org/sites/default/files/consumer-health-insurance-what-is-medical-necessity.pdf
