How Can I Get Medicare Or Medicaid Coverage For Immunocal?

Here is the information I have from Immunotec concerning Medicare and Medicaid coverage for Immunocal:

Medicare/Medicaid in the U.S.

Medicare, the U.S. federal health insurance program for people age 65 and over, people under age 65 with certain disabilities, and people of all ages with End Stage Renal Disease, in all 50 states has determined that Immunocal is eligible for coverage and reimbursement when certain requirements are met. Medicare covers Immunocal when it is prescribed for tube feeding only and pays for no more than one month’s supply of nutrients at a time. Complete coverage requirements are explained in the Medicare National Coverage Determinations Manual, Chapter 1 and the Medicare Benefit Policy Manual, Chapter 15.

Medicaid, the joint federal and state-funded program for certain categorically eligible low-income individuals and families, determines coverage and reimbursement for Immunocal on a state-by-state basis. Please see the chart below to determine whether Immunocal is eligible for coverage under a particular state’s Medicaid program. Please note that many state Medicaid programs that cover Immunocal require prior authorization. Please verify individual state Medicaid rules for specific coverage and reimbursement requirements.

Obtaining product: For both Medicare and Medicaid coverage, Immunocal must be prescribed by a licensed physician. The prescription must be taken to a pharmacy to be filled. If covered in that particular state, the pharmacy will order Immunocal from their national wholesalers. These wholesalers get the product from Immunotec’s Medical Division.

Immunotec’s Medical Division: Product for Medicare and Medicaid is handled by Immunotec’s Medical Division.

For more information: Please contact Immunotec Medical Division.
To place your order
By e-mail: medicalorders@immunotec.com
By telephone: 450-424-9992 ext. 2373
By fax: 450-424-9993 / medical department

Private Insurance Coverage

Individuals should contact their private healthcare insurance company to inquire whether Immunocal is covered if prescribed by their healthcare professional. Reimbursement will follow your insurance company’s usual protocol.

Reimbursement by State

Please see the below chart for general information. Please note, Medicaid program requirements are subject to change. Healthcare providers and patients should check with their state Medicaid agency to obtain current coverage and billing requirements to ensure compliance with state requirements.

Covered - Often priced by individual claim, frequently needs prior approval

Colorado
Connecticut
Indiana
Maine
Massachusetts
Michigan
Minnesota
Missouri – may need “exception” form
Nebraska
New Jersey
New York
North Dakota
Ohio
Oregon
Vermont
Virginia – AIDS only
Wisconsin – AIDS, wasting, Cystic Fibrosis
Wyoming


Reimbursed by calorie content

Arizona
New Mexico
Illinois – AIDS & Cancer only
Louisiana – may need “Exception” Form and must represent 70% of calorie intake some cases under 21 would cover orally
Washington
Idaho – Children only for oral and reimbursed by calorie


Coverage follows Medicare Guidelines - Tube feeding only

Hawaii – also reimburses by calorie as well
Iowa – Children only for oral and also there is disease restrictions
Kentucky – Might try “Exception” Form
Maryland – Disease restrictions
Montana
South Carolina
South Dakota
Texas – May cover children orally
Utah
Washington DC


Immunocal code not covered

Alaska
Alabama – Children may be given special consideration
Arkansas – Children only
California – TAR form
Delaware
Florida
Georgia – Oral is only children under 21
Kansas – Reimbursed by calorie as well
New Hampshire
Mississippi – May cover children orally
North Carolina
Nevada
Oklahoma – Children may be given special consideration
Pennsylvania
Puerto Rico
Rhode Island – May cover children orally, disease restrictions
Tennessee
West Virginia

All Medicare/Medicaid business is handled by the Medical Division’s Distribution Group. Since it is government reimbursement it must be handled this way so as not to be in violation of anti-kickback statutes.

Note: The NDC# for Immunocal is 28770-0970-01. You may be asked to provide this number.

This information may also be accessed online here.

If you find you are ineligible for coverage in your circumstance, you may order Immunocal directly yourself without a prescription here.