Wiki Help with - I work for a GI group

[cedwards]

I work for a GI group and have never had to deal with Sandostatin coverage before. I am a pro with Remicade, Entyvio, Humira, etc.

One of our patients was started on octreotide 100 mcg b.i.d in the hospital. The patient has not had any since because the patient cannot afford the medication through the pharmacy benefits. One of the doctors I work with wants to continue this patient on the Octreotide, which I believe is Sandostatin and he wants us to buy and bill it.

Patient has a Medicare Advantage product that tells me they will cover 80% if Medicare covers it and the patient will be responsible for 20% coinsurance.

I am trying to find the Medicare coverage policy for Sandostatin (I assume it is CPT code J2354) as well as the Medicare reimbursement rate for this so I can ensure that it will be covered for the patient and so I can give the patient a close out of pocket estimate for what the coinsurance will be.

Any help would be greatly appreciated.

Thanks!
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[nlaaron]

Who is you MAC? Also addendum B on cms should give you the opps reimbursement.

 

[melissae@phclincoln.org]

Which Mac

I also ask the question of which mac. There are two Sandostatins used, immediate release (octreotide acetate) J2354 and also LAR ( (octreotide acetate for injectable suspension) J2353. Most likely, your local mac will have the immediate release on it's self injectable list, and not eligible for part B benefits. The LAR J2353, however is billable to WPS under B benefits.

Also, make sure to check Novartis, they always have really assistance programs.

 

[cedwards]

Mac

Our MAC is National Government Services (NGS). Patient was already given the LAR in the hospital which I assume the physician wants to keep the patient on.