BOSTON – The second-largest health insurer in Massachusetts will soon stop covering specialty medications known as compounded drugs because of cost and safety concerns.
The decision by Harvard Pilgrim Health Care that takes effect Aug. 7 comes months after a deadly nationwide meningitis outbreak was traced to a Massachusetts compounding pharmacy.
Dr. Michael Sherman, the chief medical officer at Harvard Pilgrim, said the policy, which will apply to only adults, stems from a safety review after the meningitis outbreak traced to tainted steroids produced at New England Compounding Center in Framingham. Fifty-eight people died and hundreds were sickened.
Harvard Pilgrim will consider appeals on a case-by-case basis. Harvard Pilgrim said 4,200 of its members over age 18 have filled a prescription for a compounded medication in the last six months.
The insurer’s review found that most of the claims it received from patients for compounded drugs were for medications that should not be covered by a health insurer, including cosmetic, anti-aging, weight loss and homeopathic remedies, Sherman told The Boston Globe .
“This is not about denying care,” he said. “It’s about eliminating costs that don’t add value.”
Harvard Pilgrim will continue to cover compounded drugs for those under age 18 because the company’s review found appropriate use of the drugs in children.
Compounded drugs are mixed for individual patients who need formulations or doses not widely available off the shelf.
Brian Rosman, research director at Health Care for All, a Boston patient advocacy organization, said he understands the concerns but believes Harvard Pilgrim’s approach is unwarranted. “For those who need these drugs, to make them go through extra hoops seems to be unfair and makes no sense because it’s coverage they have paid for,” he said.
Two Massachusetts pharmacist groups are urging Harvard Pilgrim to reconsider the policy, saying in a letter that a compounded medication is sometimes the only drug available for patients because of drug shortages.
Blue Cross Blue Shield of Massachusetts and Tufts Health Plan, the state’s largest and third-largest health insurers, plan to continue covering compounded medications.