DISCLAMER: Product formulary positioning can change without notice and will vary by benefit design. The information provided herein does not constitute a guarantee that reimbursement will be received. Healthpoint is providing this information on an “AS IS” basis, and without warranty or guarantee, expressed or implied, as to completeness, reliability or otherwise. It is intended as general information only and provided as a courtesy and not as an authoritative basis for purchasing or clinical decisions.
REGRANEX® Gel is a biologic, self-administered drug; therefore it should be covered under a patient’s drug insurance benefit similar to other prescription drugs. There are many different payers and types of drug benefits within different market segments. Some examples are: Medicare Part D, commercial drug plans, fee-for-service state Medicaid, managed Medicaid plans within each state, and government payers like the Veterans Administration.
Medicare Part D
For the 2012 benefit year, REGRANEX® Gel is on formulary for approximately 94% of the seniors under the Part D program. Please note that approximately 75% of the patients whose plan covers Regranex Gel will have some type of formulary restriction that requires a combination of prior authorization and/or quantity limits. (Approximately 19% of seniors have unrestricted access to REGRANEX Gel.)
Tier placement for REGRANEX Gel for the Medicare Part D plans varies amongst preferred brand, non-preferred brand, or specialty tiers. Co-pay for seniors vary from a fixed co-pay range of approximately $38 to $90 per prescription to a co-insurance contribution ranging from 25% to 35% of the cost of the drug.
Commercial Drug Benefits
Healthpoint's research indicates that many of the national drug plans and pharmacy benefit managers list REGRANEX® Gel on their formulary with a mix of preferred or non-preferred positioning. You can expect to see a prior authorization requirement and/or monthly quantity limits on many of the formularies. Most of the copays appear to be a fixed dollar amount ranging from $25 to $90 per prescription.
Medicaid Fee for Service Benefit Coverage
The majority of state Medicaid agencies reimburse REGRANEX® Gel with a prior authorization requirement. In general, the conditions for approval of the prior authorization request mirror the clinical indications for REGRANEX Gel.
As more states enroll Medicaid beneficiaries into managed Medicaid plans, it is likely that coverage will vary between the plans operating in the same state.
U.S. Food and Drug Administration. Consumer Health Information (CHI). A guide to drug safety terms at FDA.
http:// www.fda.gov/downloads/ForConsumers/ConsumerUpdates/ucm107976.pdf. Last updated April 11, 2008. Last accessed July 11, 2011.