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In supporting the growth of Men’s Health Programs across the Urology space, UroGPO has always ensured that there is a targeted focus on Peyronie’s Disease Management, particularly through Xiaflex treatment access. As such, we feel it important to keep our membership up to date on recent service changes that have impacted the membership and patient access to Xiaflex treatment.
BACKGROUND
Xiaflex is a unique product in that it may be covered by a patient’s Medical or Prescription Benefit. According to Endo, approximately 40% of Xiaflex prescriptions that are sent to a Specialty Pharmacy (SP) end up being covered by, and billed to, the patient’s Medical Benefit. Historically, the SP has always completed the Prior Authorizations, and healthcare professionals (HCP) have always been responsible for completing the Benefits Investigation, with assistance from Endo Advantage™.
CURRENT SITUATION
CVS Caremark recently acquired US Bio Services, the authorized SP provider to fill Xiaflex prescriptions. As such, the SP’s Prior Authorization services have been discontinued, leaving HCPs to either allocate internal resources or work with a third party. Endo continues to offer their Xiaflex® Copay Assistance Program which assists commercially insured and cash-pay patients with out-of-pocket costs of up to $1,200 per injection. The benefits from this program can be paid directly to the practice.
RECOMMENDED ACTION
Considering both practice and patient benefit, UroGPO recommends that practices go through the medical benefit (buy-and-bill) process for all Xiaflex prescriptions, only sending the prescription to the SP if the patient’s coverage requires that it be processed under their prescription benefit. By billing the patient’s medical benefit, a practice can access the UroGPO contracted price and rebate opportunity ranging from 4%-16%. Not only do patients receive more timely treatment, but the practice revenue and ease of coverage are fully optimized.
To ensure coverage, chart documentation should include the following:
- Degree (and change in degree) of curvature
- Date of symptom onset
- Palpable plaque, not highly calcified
- Prior treatments
- Pain during intercourse or erection
WEBINAR AND RESOURCES
UroGPO will be hosting a live webinar on Wednesday, October 5th, 2022 at 12:00 p.m. EST to continue discussion and dialogue around best practices. Attendees will receive updates from Specialty Networks’ Sr. Director of Contracting, Palmer DePetro, and insight from UCLA’s Men’s Health Clinic Program Manager, Kellie Maes. See below for registration details.
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