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Drug compounding is the process of mixing, combining, or alternating ingredients to create a customized medication. This is considered experimental, investigational and unproven in most cases according to the BlueCross and BlueShield of Texas’ (BCBSTX) Medical Policy on Compounded Drugs.
The properties of certain drugs may be altered and combined by a compounding pharmacy to create a customized medication for the use in a pain pump or for progesterone therapy as a technique to reduce pre-term delivery in high-risk pregnancies. Please review the following BCBSTX Medical Policies related to Progesterone Therapy (RX501.062) and Implantable Infusion Pumps (SUR707.008) by going to http://www.bcbstx.com/provider and clicking on the “Medical Policies” link.
Compound drugs should be filed under the appropriate “Not Otherwise Classified” procedure code with the Modifier KD.
Effective August 15, 2009, in an effort to more effectively and consistently price those drugs approved under these medical policies for Progesterone Therapy and Implantable Infusion Pumps, BCBSTX is adopting the same methodology as the Centers for Medicare and Medicaid Services (CMS).
The table below shows the drug name, concentrations, and the BCBSTX reimbursement amounts that will become effective on August 15, 2009.
BCBSTX Compounded Drug Fee Schedule (Effective August 15, 2009)
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Drug Name
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Concentrations
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Reimbursement
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Baclofen
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Up to 2,000 mcg (2 mg)
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$ 71.40
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Baclofen
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2,001 to 4,000 mcg (4 mg)
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$ 148.75
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Baclofen
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Over 4,000 mcg (4 mg)
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$ 178.50
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Bupivicaine
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Up to 7.5 mg
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$ 11.90
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Bupivicaine
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Over 7.5 mg
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$ 23.80
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Clonidine
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Up to 2 mg
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$ 57.12
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Clonidine
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Over 2 mg
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$ 104.72
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Fentanyl
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Up to 1,000 mcg (1 mg)
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$ 65.45
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Fentanyl
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1,001 to 2,500 mcg (2.5 mg)
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$ 136.85
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Fentanyl
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2,501 to 5,000 mcg (5 mg)
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$ 238.00
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Fentanyl
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Over 5,000 mcg
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$ 380.80
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Hydromorphone (Dilaudid®)
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Up to 45 mg
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$ 107.10
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Hydromorphone (Dilaudid®)
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Over 45 mg
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$ 130.90
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Morphine
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Up to 45 mg
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$ 47.60
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Morphine
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Over 45 mg
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$ 71.40
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Prialt
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100 mcg
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$ 753.27
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Prialt
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200 mcg
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$ 1,548.67
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Prialt
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500 mcg
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$ 3,872.26
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Sufentanil
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Up to 50 mcg (0.05 mg)
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$ 238.00
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Sufentanil
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Up to 100 mcg (0.1 mg)
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$ 416.50
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Sufentanil
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Up to 200 mcg (0.2 mg) and above
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$ 505.75
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If you have any questions, please contact Provider Customer Service at (800) 451-0287 to speak with a Customer Advocate.
posted 5/15/09
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