Coverage Policy
The information displayed below pertains specifically to the Physician Office setting of care. For information tailored to the Hospital Outpatient setting or Pharmacy setting, please select the appropriate tab to the right. Coding, coverage, and reimbursement may vary significantly by payor, plan, patient, and setting of care. See below
Most third-party payors, including HMO plans, managed care organizations, indemnity plans and others provide coverage for FRAGMIN®. However, specific coverage requirements and restrictions depend on a patient’s benefits and will vary based on plan type and provider site of service. Some payors have established formal published policies, but the lack of a published policy from a particular payor does not mean that FRAGMIN® is not covered by that payor. In addition, commercial payors may cover FRAGMIN® as a medical benefit, a pharmacy benefit, or both. Each benefit is administered separately and may have different deductible, copayment and/or coinsurance structures. Some commercial insurers may apply coverage and utilization restrictions such as prior authorization or quantity limit edits to FRAGMIN®.
For more information on commercial payor specific coverage of FRAGMIN®, contact your health plan.
Payor Reimbursement
Commercial payor reimbursement for FRAGMIN® may be based on a percent mark-up of Average Sales Price (ASP) similar to Medicare reimbursement methodologies. Payment may also be based on a percent mark-up or mark-down of Average Wholesale Price (AWP) or Wholesale Acquisition Cost (WAC).
Administration Services
Commercial payor reimbursement for physician-related FRAGMIN® drug administration services may be based on a common fee schedule similar to the Medicare reimbursement methodology for physician services or other contracted rates.
