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How do you balance cost of postoperative steroids and NSAIDs and still keep pace with innovative medications?
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$70 for prescriptions
For cataract surgery, we use Pred-Gati-Brom (prednisolone acetate, gatifloxacin, bromfenac) from Imprimis. If the patient is upgrading in any way, including limbal relaxing incisions, the drop is included in their out-of-pocket cost, unless they have allergies that prevent them from using it or they have a preference for uncompounded drugs. If that is the case, we prescribe to their pharmacy. The drops are ordered in bulk under 503B and cost $70 per patient for a 7 mL bottle.
If a patient receives a traditional lens only, we offer the option of prescribing the drop to Imprimis. It is sent here, and the patient pays $70 for it the day of surgery. They pay no more than what we pay to Imprimis, so essentially they are just reimbursing us. The reason we do not prescribe individually to the patient from Imprimis is that we have an inordinate number of patients who lose their drops before surgery or do not bring the drops with them the day of surgery. This way we have better control and fewer phone calls.
Jeffrey Whitman, MD, is an OSN Cataract Surgery Board Member. Disclosure: Whitman reports no relevant financial disclosures.
Compounding pharmacies are an option
Even though generics are generally covered by insurance and cheaper, we as a group shy away from generics for various reasons, one being lack of evidence regarding efficacy and toxicity, as well as uncertainty regarding the components. We do about 4,000 cataracts a year, which leaves us with using branded or novel therapies.
As far as branded therapies go, we have reached out to several independent pharmacies that will take the extra step of looking at whether opting people in or out of their insurance would be the better avenue regarding out-of-pocket cost. There are times when drug plan prices are more expensive than when promotional coupons without insurance coverage are used. Promotional coupons are available for most of the branded NSAIDs and steroids.
For example, a Medicare patient may have to pay $150 or $250 for one bottle of branded NSAID or steroid, whereas without insurance and with the coupons, the price goes down to $50 or $60.
We also use 503A and 503B compounding pharmacies. Imprimis and Ocular Science are two of the bigger ones. These compounding pharmacies can mix the NSAIDs with steroids, so the patient needs to buy only one formulation and uses fewer overall drops. On average, the combination drops cost $50, which is significantly cheaper than buying two bottles of branded medications or even the generics. Another advantage is the reduced preservative load in the combined product rather than individual products. You have cost savings, compliance and preservation of the ocular surface. The downsides are that the combination is not an FDA-approved product and there is lack of data showing efficacy. You have to go with common sense as far as what the efficacy may be. Ocular Science sets itself apart by doing its own efficacy studies that are presented and published, but they are small studies and not FDA approved.
A 503B compounding pharmacy such as Imprimis can ship product to the practice and the practice can sell it to the patient. A 503A compounding pharmacy requires a prescription for the product, then the product is sent to the patient or to the clinician.
Newer products that are FDA approved but not yet available include EyePoint’s Dexycu (dexamethasone intraocular suspension 9%) in a Verisome drug delivery vehicle, which is injected at the end of surgery, and Ocular Therapeutix’s Dextenza (dexamethasone ophthalmic insert 0.4 mg), which delivers dexamethasone via the punctum, akin to a punctal plug. Both are anticipated to receive pass-through status, so insurance would cover the cost. Compliance is 100% owing to the novel delivery methods.
At our surgical center, we do use a compounded antibiotic and steroid at the end of surgery that helps with compliance, and we eat that cost but the patient saves. Our managers strongly believe it is better for patient compliance and their outcomes.
Francis S. Mah, MD, is an OSN Cornea/External Disease Board Member. Disclosure: Mah reports he is a consultant with Allergan, Bausch + Lomb, EyePoint Pharmaceuticals, Ocular Science, Ocular Therapeutix, PolyActiva and Sun Pharmaceuticals.
Editor's note: This article has been updated to correctly differentiate descriptions of 503A and 503B designations for compounding pharmacies.