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Author Topic: XIAFLEX Insurance coverage basics  (Read 2830 times)

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Stabler

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XIAFLEX Insurance coverage basics
« on: February 19, 2017, 10:14:45 AM »

Xiaflex is covered by most US health plan, it does require a precertification/authorization that will need to be done by the physician that is prescribing it. make sure that you are seeing a physician that specializes in peyronies so that it will not be denied by your insurance plan. A denial for Xiaflex will in most cases mean an appeal and those do not always end well.

The thing you have to understand is that all insurance plans are NOT the same. BCBS does NOT mean ALL BCBS, plans vary, this is true for all insurance carriers, so you have to do your homework.

Xiaflex injections use a J code for identification (CPT Code) J0775

When calling to check out a plan ask them....

Is this code is a COVERED benefit, and is it covered under Medical or Pharmacy

Does it require an authorization and if so, do you have to use a Specialty Pharmacy, if you do ask which one you have to use.

Do you have to Try/fail other medications before you can use Xiaflex.

What is my coverage for Xiaflex (deductible, Co Insurance, Out of pocket) this way you know YOUR financial responsibility up front.

If the plan wants to know a diagnosis code or (ICD-10 code) that will be N48.6
this is the code for Peyronies Disease

Now, your doctors office will handle the approval for the medication but... YOU need to know your benefits before you go in blind. Always get a name of whom you are speaking with at the insurance company and a reference number for the call if they give them (you have to ask) in case you have to go back to check something then you have proof of what you were told.

Hope this helps
Stabler67
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Moderator since 2015- Missouri- I work in the medical field and have strong knowledge of insurance and how to obtain coverage for medication and other treatments. Being a woman I do not have Peyronies but you can ask me anything. I am happy to help.

Sadan9

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Re: XIAFLEX Insurance coverage basics
« Reply #1 on: June 06, 2017, 07:30:32 PM »

Sadan9:
Fortunate My Humana Gold Medicare covered a portion then Doctors office was able to get me a $5,600 grant to cover my deductible. Thank God for that other wise I would have been unable to have Xiaflex injections as I am on disability. My out of pocket cost should be $o. I can't believe it. I am so grateful.
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chasema

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Re: XIAFLEX Insurance coverage basics
« Reply #2 on: May 17, 2018, 01:57:56 PM »

Just called hospital for coding. They gave me 54205 for Xiaflex injections.
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Stabler

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Re: XIAFLEX Insurance coverage basics
« Reply #3 on: May 17, 2018, 06:33:44 PM »

J0775 is the CPT code for the medication- the code they gave you may be a code for administration of the medication but not the med itself. Xiaflex is a specialty med and when your doctor goes to get it approved they J code is what it will be billed under.

Stabler67
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Moderator since 2015- Missouri- I work in the medical field and have strong knowledge of insurance and how to obtain coverage for medication and other treatments. Being a woman I do not have Peyronies but you can ask me anything. I am happy to help.
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