Personalized medicine is the practice in which a licensed pharmacist combines, mixes or alters ingredients in response to a prescription by a licensed practitioner to create customized formulations for patients and animals whose health care needs cannot be met by standardized medications manufactured by the pharmaceutical industry.
Personalizing medicine is a centuries-old practice. Pharmacy is one of the most respected and trusted professions in the United States. In a recent survey, pharmacists ranked as the second most trusted professionals in our society behind nurses. Today, personalized medicine has evolved into a specialty practice within the pharmacy community.
Millions of patients have unique health needs that off-the-shelf, manufactured medications cannot meet. For these patients, personalized medications are the only way to better health. Working with a physician, a pharmacist skilled in the art and science of personalized medicine can meet individual needs of children, adults and animals. Whether it’s an allergy to an ingredient, a need for a different strength, or a preference for a different dosage form, specialized pharmacist provide patients with solutions to their medication needs.
Many Americans now have some type of prescription drug coverage through their employer or through a government assisted program. Whether you pay a fixed copayment, percentage of your total prescription cost or pay out-of-pocket and then submit your receipts for reimbursement, prescription drugs are one of the most commonly used of all health insurance benefits.
Depending on the plan and the insurance company you have selected, personalized medications are often covered in the same manner as commercially available drug products. You can ask your pharmacist or check to find out if your medication is covered, to what extent it’s covered, and the amount of out-of-pocket cost you can expect.
The insurance companies, as a whole, do a great job assessing the risks vs benefits of thousands of commercially available medications by creating tiers based on safety, efficacy and cost effectiveness of drugs. However, insurance companies actually contract with an outside business called a Prescription Benefit Manager (PBM) to process their prescription claims. PBMs are not insurance companies and are not regulated by Insurance Commissioners in most cases. PBMs can obtain rebates and discounts from pharmaceutical drug companies, get paid by the insurance company for each claim they process, and take a percentage from each. In a way they act as the “middle man”.
Recently, a few of the larger PBMs have launched new programs that will exclude a majority of personalized prescriptions from coverage. The goal of this program is to save the PBMs money; however, it may unintentionally prevent access to personalized medications that you rely on.
As more doctors and patients recognize the health benefits of a personalized prescription drug, more claims are being submitted to PBMs for processing. PBMs are expecting you, the patient, to pay the entire out-of-pocket cost of the medicine. In my opinion, that is simply unfair. Patients requiring personalized medicine should receive the same types of coverage that’s offered for non-personalized medicines. For additional information on personalized medicine and how you can protect it please visit www.protectmycompounds.com.
Dr. Bob Harshbarger, III is a graduate of Mercer University College of Pharmacy & Health Sciences in Atlanta, GA and is licensed to practice pharmacy in the states of Kentucky, Louisiana, Maryland, Tennessee and Virginia.