Reimbursement on Spinraza, Ocrevus and Radicava

[ornithoptor]

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I work for large IDN on Rx revenue and reimbursement and our Neurologist are asking the infusion center to begin carrying these drugs.

However, limited payor policies are available. Some want buy and bill and some requires specialty. Do any of you have experience with these drugs.

Has anyone received claims on these? Does anyone know what I can realistically expect from payors other than Medicare. I am looking for answers other than percentage of charges.

BTW, first year cost is about $750K at cost, not charge.

Thanks


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[JustAnotherRph]

We do not recognize any of the drugs as a pharmacy benefit for our Medicaid plans. In fact, our claims processor went so far to inactive the GPI so they can't every pay through pharmacy.

 

[ChalupaBatman86]

Why don't you just wait until there is a specific order for a patient and then check their coverage? Do you really need to keep it in stock?


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[rph3664]

BTW, first year cost is about $750K at cost, not charge.

 

[ornithoptor]

We do not recognize any of the drugs as a pharmacy benefit for our Medicaid plans. In fact, our claims processor went so far to inactive the GPI so they can't every pay through pharmacy.

That is the whole point. We only get limited definitive answers from payors and none denial is not the same as approval. Furthermore, what kind copay or deductible are patients looking at? Do we take their house if payor gives non denial but eventually denies it?

Although our state Medicaid has not recognized them, drafted policy are in place. Medicaid and Medicare are good cause once policy approval is there, we can project reimbursement with some certainty. Even if we don't like the amount reimbursed.


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[ornithoptor]

Why don't you just wait until there is a specific order for a patient and then check their coverage? Do you really need to keep it in stock?


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We do not stock them and that is not our worry so much. We either buy and bill or through specialty. Inventory loss is not of a concern. It is more of a reimbursement amount that we are worried, as well as coinsurance for patients. Do we expect heavy write off or take patient's house?

We have patients lined up wanting this and likely will begin infusion soon. We can uncover patients are not covered 3 months after treatments, and patients will be responsible for the amounts charged.

That is the reason why I am trying to find out if any other pharmacist have dealt with this already?

Thanks


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[Lnsean]

We can uncover patients are not covered 3 months after treatments, and patients will be responsible for the amounts charged.



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HUH? Is this real right now?