Coverage, access, and reimbursement will vary by state as well as by the patient's Medicaid eligibility status, so it is important to verify a patient's Medicaid program benefits for Synvisc-One® and SYNVISC®.
In addition, you should confirm whether Medicaid patients have other forms of insurance. Medicaid is the payer of last resort, so in cases where patients have Medicare or other types of supplemental commercial insurance, Medicaid always pays secondary or tertiary to these payers.
State Medicaid programs cover drugs under the medical and/or pharmacy benefit(s). Physician-administered products, like Synvisc-One and SYNVISC, generally are covered under the medical benefit.
Some states, however, may manage drug coverage and reimbursement through the pharmacy benefit. In these cases, patients obtain the drug at a pharmacy and bring it to the physician's office for administration. In addition to confirming a patient's eligibility and benefits under Medicaid, it is important to confirm under what guidelines Synvisc-One and SYNVISC should be obtained. For example, some states may place quantity restrictions on the number of prescriptions filled per month, some may require that patients obtain the product through specific retail pharmacies, and others may require PA.
States mandate their individual drug reimbursement methods. While methods vary, state Medicaid agencies usually pay for products administered in the office and hospital outpatient settings based on AWP or ASP. Medicaid payment policies for Synvisc-One and SYNVISC administration and associated office visits typically are similar to those under Medicare, with reimbursement structured according to a physician fee schedule.
Providers retain sole responsibility for determining reimbursement and insurance issues related to their patients and for ensuring the accuracy of their submission claims. Sanofi cannot be responsible for failure of a provider to obtain reimbursement.