With the onset of H1N1 flu and the shortage of Tamiflu to treat it, community pharmacists are working hard to stretch the supply by making multiple liquid doses for children from adult capsules (or caps, for short). Community pharmacists have experienced some problems in this area, which NCPA chronicled here and here.
In Wednesday’s edition, USA TODAY chronicled the price variation in pharmacist-compounded Tamiflu, but failed to explain the factors behind it
My colleague John Coster, RPh and NCPA Senior Vice President of Government Affairs, summed it up well in an email earlier today. Here are some excerpts from it:
“First, almost 95% of all prescriptions are paid by third parties, so just because a pharmacy tells someone a price for a prescription, that doesn’t mean that’s what they get reimbursed. The pharmacy has a ‘usual and customary’ charge for cash paying customers, but that’s a very small percent of the average pharmacy’s business. So, because the pharmacy told a reporter a specific price, that doesn’t mean they will get paid that by the third party. In addition, early on many of our members were having difficulty getting the PBMs (CVS/Caremark in particular) in agreeing to even reimburse pharmacies for compounding Tamiflu prescriptions. Many third parties don’t pay for compounds.
“Tamiflu suspension is commercially unavailable so pharmacists have to compound the suspension out of Tamiflu caps. They also need other ingredients such as cherry syrup (in which the capsule powder is suspended).
“The commercially-available caps come in 30mg, 45mg, and 75mg and ARE ALL THE SAME COST PER CAPSULE (about $9-10/capsule). The 75 mg capsules are difficult to obtain right now. Independents may have a harder time getting the larger capsule size because the chains may be buying them all up, leaving the independent with what’s left in the market.
“The total cost of the prescription can depend on dose per day and number of doses prescribed. The total number of capsules needed also depend on the child’s weight. The total quantity dispensed can also vary – for example, the prescriber could order 2 ounces or 4 ounces.
“For example, if the pharmacist had to compound a treatment regimen that called for 30mg twice a day for 5 days, the pharmacist needs 300mg. If the 75mg caps are available, they can use 4 caps for a NET cost of $32-$40 or if only 30mg caps are available it would take 10 capsules (NET cost of $90-$100). The pharmacist can add a compounding fee to this prescription, and also have to recover the costs of the other ingredients, such as cherry syrup.
“Other minor reasons for variation could include location (rent is higher in urban areas, like NYC).”