United Health Care: Buy and Bill

[insomniac]

Hi Everyone,

I'm hoping perhaps that someone on here has had recent experience with United Health. They say that they cover Xiaflex injections but only with a "Buy and Bill" mechanism, according to the first urologist I consulted with who specializes in these injections. They were not able to help me as they use their own pharmacy.

When I spoke to United, they didn't seem to have any understanding of this at all, and say that that it's a medication that is covered. Another urologist I consulted with basically explained that United requires the doctor to pay out of pocket for the medication then get reimbursed by United, which could potentially be denied. Which...most urologists understandably don't wan to take the risk for very little profit for them.

Anyone have similar experience, and a success story on how to navigate this? It may be that United makes it so difficult as a way to effectively deny coverage of Xiaflex, even though they say they do, by making it so unattractive for providers to comply. So I might be flying to Mexico perhaps...who knows...

[dannys1s1]

I had UHC during 4 rounds of Xiaflex last year and early 2021 and had 0 issues with them paying for the treatments. It may be plan specific so perhaps that is an important distinction. I would call up the manufacturer www.xiaflex.com 1-800-462-ENDO (3636) and explain to them the issue you are encountering. Once you get this all sorted out perhaps you will have better results than I did. Good luck.

[Stabler]

Hello,

Buy and Bill simply means that it is purchased and given by the provider (your urologist) so that it will be covered under the MEDICAL side of your benefits. This medication is not one that would go through your pharmacy benefits like a regular prescription would.

Stabler

[insomniac]

Thank you. Yes my provider's office finally called the manufacturer and supposedly got the right , but the last thing I heard is is it got denied again by my insurance (United). I don't think United really wants to pay for this medication. Perhaps something has changed since the last time anyone here has tried to get Xiaflex prescribed with United. Seems like everyone else I've spoken with don't have problems with with other insurance carriers.

[Stabler]

If it was denied your urologist can appeal for you to have it covered. He would need to provide documentation showing all of you diagnosis codes meds you have already tried as well as any other therapies you may have tried. You can also appeal on your own but it is better for your urologist to do the appeal because they will be able to provide the exact information needed to get it approved.

Stabler

[insomniac]

Thank you for the reply. Yes, I'm talking with their insurance team, and we'll see how it goes. The provider recommended finding another independent urologist that will work in the "Buy and Bill" manner. If anyone knows of a urologist in the Puget Sound area who operates in this manner, please let me know.