Reimbursement FAQs

Can a patient with primary immunodeficiency disease (PIDD) be reimbursed for subcutaneous immunoglobulin (SCIG) treatment through Medicare Part D? Historically, SCIG has been reimbursed through Medicare Part B.

By statute, SCIG falls under Medicare Part B. However, some drug plans, including Medicare Advantage Plans with prescription drug coverage, allow PIDD patients to access SCIG utilizing the prescription benefit. Patients should be advised, however, that unlike Part B, the drug plans do not reimburse for the cost of supplies or the pump. Additionally, if the IG product falls under the specialty tier in the drug plan, the patient could be charged up to a 33 percent coinsurance fee. For stand-alone Part D plans, patients also could be subject to paying 100 percent of the cost of the drug when they fall into the doughnut hole.

Can a patient request a change in a subcutaneous immune globulin (SCIG) prescription if the insurance company charges a copayment for every different vial size needed to fill that prescription?

While a separate copayment for different vial sizes of IG has not been a widespread problem, as health plans continue to move IG to the prescription benefit, it may become so.

In the retail pharmacy arena, it is common for patients to be charged a separate copay for each drug with a different national drug code (NDC) number. Every drug is required to be labeled with a unique NDC number for each strength of the medication, even if it is the same formula. Retail pharmacists usually can figure out a way to fill a prescription without using two different strengths of the medication. However, IG dosing is not as simple as, for instance, antibiotic dosing. This is because optimal dosing for many diseases treated by IG has not yet been established, and patient dosing varies greatly based on the individual patient’s weight and disease state. Therefore, it is nearly impossible for manufacturers to produce every possible dosage in their manufacturing process.

So far, patients have been able to overcome this issue by contacting their health plan’s case manager or pharmacy benefit manager to request an override so they are charged only one copay. Additionally, patients and doctors can request information about how the IG can be billed as part of the major medical benefit. If the IG can be billed through a clinic or under the home infusion benefit, it likely will fall back under the major medical portion of the healthcare plan.

Editor’s Note: The content of this column isintended to provide a general guide to the subject matter. Specialist advice should be sought about yourspecific circumstance