XIAFLEX Insurance coverage basics

Previous topic - Next topic

0 Members and 1 Guest are viewing this topic.

Stabler

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
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

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.

chasema

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

Stabler

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
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.

Sebtp1973

Endo will reimburse your out of pocket expense not covered by your insurance. See here: https://peyronies-disease.xiaflex.com/hcp/access-reimbursement/

They say around 90% of patients pay zero out of pocket with their co pay assistance.
57 yrs old.
Pre-Trost treatment, 110 composite curve (75 up, 35 left)
Post-Trost xiaflex treatment, 0-15 degree curve.

Stabler

Sebtp1963

This is a good program BUT all members need to make sure to read the eligibility section of this site. Not everyone would qualify for the assistance.

Stabler  
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.

TheCrookedFerret

Hey Stabler, has anything changed regarding the "codes" you referenced back in 2017? You know how insurance companies can be "major dicks" when we are looking for help with ours.
42, Chronic/stable, began 3/2010
Started with 30, down to a 15 degree curve left. Pea sized palpable plaque still remains, "but slowly softening". Soma Therapy pump, Duputrensco Cream, and Hyaluronic Acid applied twice daily.

Stabler

Hello CrookedFerret,

Yes the codes I have given are still accurate, keep in mind that if your providers are using different codes you need to be checking what they are and stand for and how they will be covered by the plan you have.

Stabler
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.

zrx1200mn

Quote from: Stabler on August 20, 2022, 06:19:16 PMSebtp1963

This is a good program BUT all members need to make sure to read the eligibility section of this site. Not everyone would qualify for the assistance.

Stabler

message I received from the Urologist office:
"Endo Pharmaceuticals has a copay assistance program that you may be eligible for. This copay assistance program is subject to approval and there is no guarantee of payment. If you are approved for the copay assistance program, they may reimburse up to $1,200.00 per injection. Again, there is not guarantee of approval for this copay assistance."
I will need to review Endo's website to see if I qualify. I'm scheduled for your injections on September 25th and September 28th.
Age 60

I've had Peyronies Disease for about 20 months. since fall of 2021
I started using RestoreX in late September, 2021.
30 degree curvature to the right. as of May, 2023 the curvature is Still 30 degrees.
first round of Xialflex shots in late September, 2023.

Stabler

Sebtp1963

Please make sure that you apply and have a decision before going for the injections. You don't want to be caught having to pay out of pocket if you don't qualify for the assistance.

Stabler
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.