Evaluating ​compounded ​medications

17 ​questions that can help

As a payer, you may be hearing a good deal of conversation, as well as seeing increased use, of compounded medications. Although controversial in both workers’ compensation and group health, payers should evaluate the use of compounded medications based on the specific needs of the injured person. To help with this evaluation, we’ve compiled a list of questions which can help you carefully consider the use of compounded medications, and guide the course to better outcomes.

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1. Has an adequate trial of first-line, oral medications been completed?
If you’re seeing a compounded medication without first-line, oral medications, investigate why.

2. Are first-line oral agents available?
There could be a shortage of commercially available first-line oral agents, or perhaps none exist.

3. Why is the patient unable to use oral medicines?
It’s helpful to know why the patient cannot tolerate oral medicines, such as trouble swallowing.

4. Are there any comorbidity conditions that might prevent the use of oral formulations?
 Underlying conditions may necessitate the use of a topical approach to pain management rather than using oral nonsteroidal anti-inflammatory drugs (NSAIDs).

5. Does the patient have any allergies that might prevent the use of oral formulations?
An oral medication that does not contain the allergen may perform as well, if not better.

6. Have other non-compounded, topical medications been tried?
Many commercially available and over-the-counter topical medications may provide the same relief.

7. Is the condition being treated compensable?
Ensure the purpose of the compounded medication is related to the injury.

8. Are all the ingredients appropriate for the condition being treated?
For example, a prescription for anticonvulsants wouldn’t make sense for an injury that doesn’t involve neuropathic pain.

9. Are the ingredients effective according to evidence-based guidelines?
What do the Official Disability Guidelines (ODG) and American College of Occupational and Environmental Medicine (ACOEM) say about the ingredients of the compounded medication in relation to the injury?

10. Does the prescriber have any literature to support the use of the compound?
Compounded medications are not subject to clinical trials; however, studies may exist on the efficacy of the individual ingredients and/or the compound itself.

11. Is there therapy class duplication with current oral medications?
Therapeutic duplication increases the risk of drug-drug interactions, over-medicating, and other complications.

12. Is there ingredient duplication within the compounded medication itself?

Lidocaine and Benzocaine, for example, are both local anesthetics, and not necessary in one compound.

13. Has there been an associated decrease in opioid utilization?
If the opioid level has remained the same—or increased— because of the ingredients in the compounded medication, it may not be the right course of therapy.

14. Has the patient demonstrated improvement in function and/or quality of life?

No reported improvement is a red flag that the medication therapy is in need of review.

15. How long does the prescriber plan on prescribing the compound medication?
The patient, payer, and physician should be aligned in their understanding of the treatment plan, its intended duration, and objectives.

16. Will a compounded medication cost less long-term than multiple oral medications?
All things being equal, look at the overall costs and determine what is the safest, most cost-effective approach.

17. How does the pricing of the compounded medication compare with the cost to create it?
 Identify the price at the ingredient level and compare it to the price paid for the compounded formulation.

Having started a dialogue with the physician, you may find that more questions arise or additional guidance is necessary. Don’t let this be discouraging or otherwise cause alarmed. When you generate a conversation with the injured worker, physician, and pharmacist, you open the door to understanding. Not to mention that in such situations, a pharmacy benefit manager can be a valuable resource, helping to illuminate the optimal path to better outcomes for everyone.