Reimbursement Guide
- Coverage of Initial Therapy with Immediate Release Sandostatin® Injection
- Coverage of Long-term Therapy with Sandostatin LAR® Depot
- Appealing Denied Claims
Sandostatin LAR® Depot Coverage at a Glance
To understand your patient's coverage, you need to know that:
- Most private medical insurance plans will cover for immediate release Sandostatin® Injection and Sandostatin LAR® Depot (octreotide acetate for injectable suspension) through a patient's pharmacy benefit.
- Patients without a pharmacy benefit through their primary insurer should determine whether they have coverage for immediate release Sandostatin® Injection through secondary insurance.
- Generally, Medicaid does provide coverage for immediate release Sandostatin® Injection.
- Medicare does not provide coverage for self-administered injectable therapy.
Coverage of Initial Therapy with Immediate Release Sandostatin® Injection
Most private medical insurance plans will cover immediate release Sandostatin® (octreotide acetate) Injection through a patient's pharmacy benefit. Patients who do not have a pharmacy benefit through their primary insurer should determine whether they have coverage for immediate release Sandostatin® Injection through secondary insurance. The Sandostatin® Therapy Support Hotline (1-877-LAR-HELP) can assist you in determining a patient's insurance coverage for immediate release Sandostatin® Injection.
Medicare does not provide coverage for self-administered injectable therapy. To assist some of these patients, as well as to assist some patients who do not have a prescription drug benefit, Novartis has set up the Sandostatin® Starter Program, a complimentary program that provides 2-4 weeks of immediate release Sandostatin® Injection. Download an application form (PDF 100KB).
Coverage of Long-Term Therapy with Sandostatin LAR® Depot
Private insurers and Medicare generally cover medically necessary drugs provided in the physician's office and outpatient clinic settings. However, some plans may have special requirements as to how the drug should be purchased, or what kind of provider should inject it. Download sample letters of medical necessity or a sample letter of prior authorization.
The Sandostatin® Therapy Support Hotline can help health care professionals determine plan-specific coverage, referrals, prior authorization, and reimbursement policies.
Appealing Denied Claims
Insurers may deny claims for a variety of reasons. Often, physicians can successfully appeal denied claims if the treatment is medically necessary and given for an appropriate indication. To help prevent inappropriately denied claims, it is suggested that the prescriber contact the patient's insurer to determine if letters of Medical Necessity and/or Prior Authorization are required before administering the product. The Hotline can assist you with this step.
To appeal a denied claim follow these steps:
- Step 1. Carefully review the patient's explanation of benefits (EOB) from the insurer. Often claims are denied because of missing identification numbers, patient names, or signatures.
- Step 2. If you have ruled out claims submission errors, you may need to support the claim by documenting medical necessity. Insurers may deny coverage if they are not familiar with Sandostatin LAR® Depot. Resubmit the claim with a letter of medical necessity that highlights the following:
- The patient's medical history
- Other therapies that have been tried
- The reason Sandostatin LAR® Depot was prescribed for this patient
- The risks of foregoing Sandostatin LAR® Depot treatment
- A Sandostatin LAR® Depot package insert (PDF 332KB)
- Peer-reviewed articles concerning the use of Sandostatin LAR® Depot
- An invoice
- Step 3. If a second claim is denied, the Sandostatin® Therapy Support Hotline, at 1-877-LAR-HELP, can assist you in following up with insurers and submitting the necessary documentation. You may also advise the patient to call the insurer to request a hearing.
- Step 4. Encourage patients to contact their benefits office regarding denied claims and talk to the benefits manager, if necessary. Remember that many efforts to pursue coverage and payment are successful, although the process may be lengthy.
Reimbursement in Private Practice Settings
Your patients' reimbursement depends on their insurance coverage:
- Medicare establishes payment levels based on a drug pricing file that the Centers for Medicare and Medicaid Services (CMS) established as a national payment allowance for each drug; this Average Sales Price (ASP) is updated on a quarterly basis. A pricing file is available on the individual Medicare carriers' websites, or you may call the Sandostatin® Therapy Support Hotline at 1-877-LAR-HELP. Medicare considers reimbursement at 80% of its allowable amount for the item; the patient, or his/her secondary insurer is responsible for the remaining 20%.
- Private Payers typically reimburse for physician services based on charges, or discounted charges, or on a fee schedule. Private payers may reimburse for Sandostatin LAR® Depot based on a percentage of charges for the drug, on the average wholesale price, on a fee schedule, or on a calculation based on the CMS pricing file.
- Most Medicaid programs reimburse physicians for their services according to a fee schedule, and for drugs according to estimated or actual acquisition cost. You can call the Sandostatin® Therapy Support Hotline to determine coverage levels for your patient.
Reimbursement in Hospital Outpatient Settings
Reimbursement in the outpatient setting depends on your patient's coverage:
- Medicare recognizes J2353 (Octreotide injection, depot) as the code to use for billing Sandostatin LAR® Depot, effective January 1, 2004. Code J2353 is linked to Ambulatory Payment Classification (APC) code 1207 in the hospital outpatient setting. Currently, Sandostatin LAR® Depot has been classified as a "K" status in the APC. Drugs and biologicals with a "K" status are paid in separate APCs in the Outpatient Prospective Payment System (OPPS). The payment rates for APCs are updated periodically. Call the Sandostatin® Therapy Support Hotline at 1-877-LAR-HELP to obtain the current payment rates.
- Note: effective July 1, 2003, the Centers for Medicare and Medicaid Services (CMS) revised Medicare's Hospital OPPS. The OPPS Pricer reflects Ambulatory Payment Classification Codes (APC) including the additions, changes, and revisions that were put in place in July 2003.
- Most Private Payers reimburse for hospital outpatient care based on charges, discounted charges, or costs. Typically, insurers pay 80% of the allowed charge or cost. Patients are responsible for a 20% coinsurance payment.
