Synvisc/Orthovisc Coverage on Medicare Advantage

[wehotex]

I have a frantic customer who is screaming at me because Aetna Specialty Rx wants to charge him $509 for this injection. However, when I look up these rx on different formularies (Humana, United & Aetna), these are either NOT LISTED or t reads that these are covered under Part B. They are injectables after all. This irate customer tells me that this same rx was covered before at the doctor's office without issue and not much costs. I find that a little hard to believe. Does anyone have experience with how they bill this on an MA plan? I imagine that it's 20% even though the man says differently.

 

[JimmyUt]

I have a frantic customer who is screaming at me because Aetna Specialty Rx wants to charge him $509 for this injection. However, when I look up these rx on different formularies (Humana, United & Aetna), these are either NOT LISTED or t reads that these are covered under Part B. They are injectables after all. This irate customer tells me that this same rx was covered before at the doctor's office without issue and not much costs. I find that a little hard to believe. Does anyone have experience with how they bill this on an MA plan? I imagine that it's 20% even though the man says differently.

I am not sure how exactly it is supposed to be covered,but my mom is on United and got it done for the specialist copay at the doc.

 

[wehotex]

I am not sure how exactly it is supposed to be covered,but my mom is on United and got it done for the specialist copay at the doc.

I followed up with the office mgr at Dr's office today. I found outfits that office keeps a supply of SUPARTZ, which is an injectible similar to Orthovisc. Dr (Rheum) doesn't accept many insurances. The only MA that he does accept is CIP, which is just like having Medicare only in my neck of the woods. The injectible with 20% Medicare coinsurance is like about $25 for the pt with no prior authorization needed. Since mb is LIS, I told them to just join a Part D through Medicare which would drop the Aetna. She can always rejoin another MA with me later if she wants to.