Insurance Coverage for ure-Na


For help with reimbursement please call 1-844-980-9933 and leave a message to be called back by a reimbursement specialist.

The NDC code for ure-Na for Insurance Prior Authorization is 62530-0000-11

The HCPCS code typically used for coverage under Medical Benefit: B4155



Health Insurance in the USA typically offers two types of coverage:

Medical Benefit and Pharmaceutical Benefit

Since ure-Na is a Medical Food, not a Pharmaceutical, it may be covered under either the Medical Benefit of you health insurance or your Pharmaceutical Benefit. Where coverage may be obtained varies by health insurance plan.

ure-Na often requires Prior Authorization (PA) to gain coverage under either benefit type.

The section below reviews coverage options for the following insurance types:
Medicare Advantage
Medicaid or Medicare/Medicaid Dual Eligible
Medicare Part D
Commercial
VA
Tricare
Indian Health Service



Medicare Advantage
Many Medicare Advantage plans offer expanded coverage in 2019 for OTCs & Medical Foods, like ure-Na. Coverage may be obtained from your Supplemental Benefit, Primary Health Related Supplemental Benefit, or DME (Durable Medical Equipment) Benefit for Enteral Nutritional Therapy. You will have to contact your Medicare Advantage plan and ask what the coverage process is for OTCs & Medical Foods under the Supplemental Benefit, Primary Health Related Supplemental Benefit or DME benefit. All of these benefits are under the Health Benefit of your Medicare Advantage plan, not your Pharmaceutical Benefit.

To gain coverage from the Supplemental Benefit, Primary Health Related Supplemental Benefit or DME Benefit, ure-Na has to be recommended by a qualified Health Care Provider and has to be considered Medically Necessary.


You may also gain coverage for ure-Na under your Medicare Advantage Pharmacy Benefit.

To gain coverage for ure-Na under either of these benefits, you will need to contact your insurance carrier and ask how authorization is gained. Often times there is a form that has to be filled out and signed by the doctor who is recommending ure-Na. Your insurance carrier may require that the Doctor recommending ure-Na document that it is Medically Necessary.

If you reach out to your insurance carrier and you speak with an agent and they state that ure-Na is not covered, ask them how to request coverage and a medical review of your request for coverage.

Insurance Carriers have a process to review and authorize coverage for products like ure-Na.


VA Benefit
Ure-Na is on the VA National Formulary (VANF) listed as: UREA15GM/PKT/PWDR,ORAL.

If you are currently receiving pharmacy benefit from the VA, ure-Na is available as the above listed item.

If you qualify for VA benefit, but you are not currently receiving benefit, please contact your local VA for more information on how to receive VA medical and outpatient pharmacy benefit.


Medicaid or Medicare/Medicaid Dual Eligible

Ure-Na may be covered under your State Medicaid plan or under your Medicare Part D plan if you are also Medicaid eligible. Medicaid may offer coverage under your prescription benefit for the coverage of OTCs or under your Medical Benefit for Medical Foods. Sometimes the ure-Na is covered under you DME or Durable Medical Equipment benefit for Enteral Nutritional Therapy.

Medicare Part D may offer reimbursement of OTCs under your prescription drug benefit.


Please contact your State Medicaid plan or your Medicare Part D plan for coverage options. To be qualified for coverage, ure-Na has to be recommended by a qualified Health Care Provider. Sometimes ure-Na may be covered after an initial Prior Authorization and sometimes upon appeal if the initial Prior Authorization is denied.


Commercial Insurance
Commercial Insurance is coverage from your employer or from the ACA (Obama Care). Reimbursement coverage for ure-Na may be obtained under a supplemental benefit for OTCs & Medical Foods or under your DME (Durable Medical Equipment) Benefit for Enteral Nutritional Therapy as part of your Medical Benefit or from your Pharmacy Benefit if your plan offers coverage for OTCs.

For coverage, ure-Na has to be recommended by a qualified Health Care Provider and be considered Medically Necessary.

You will need to reach out to your insurance and ask about coverage options of OTCs & Medical Foods as most plans are different.



Medicare Part D
Medicare Part D is prescription drug coverage for Medicare enrollees. Reimbursement coverage may be obtained from your prescription benefit when a Prior Authorization is submitted to a Medicare Part D provider (sometimes called sponsor).

Coverage for ure-Na may be denied stating that the Medicare Part D Act does not allow coverage of OTC products. This is partially true in that the Act is for coverage of prescription drug products and it specifically denies coverage for OTC products under the the prescription drug benefit.

However.

The Act was revised to allow coverage of OTCs via the Insurers Administrative Costs Structure.
Chapter 6 Section 10.10 of the Medicare Prescription Drug Benefit Manual specifically states:

10.10 - Over-the-Counter Products (OTCs) (Rev. 2, Issued: 07-18-08; Effective/Implementation Date: 07-18-08) The definition of a Part D drug does not include OTCs. Therefore, Part D sponsors cannot cover OTCs under their basic prescription drug benefit or as a supplemental benefit under enhanced alternative coverage. However, CMS will allow Part D sponsors the option to provide OTCs as part of their administrative costs structure. Refer to chapter 7, section 60, of this manual for further discussion of this option.


If coverage from the Prior Authorization is denied, there is often times an appeal option. Typically the Insurer or Medicare Part D Sponsor sends a letter to the covered patient and sometimes to the Health Care Provider as well as to why it was denied and what appeal options are available.

If coverage is denied because OTCs are not covered under the
Prescription Drug Benefit, requesting coverage under the plans administrative cost structure may be an option.



More information can be found on this subject at the Medicare (CMS) website by clicking here
.


Tricare
Since ure-Na is a Medical Food, Tricare may offer coverage under your Medical Benefit for Nutritional Therapy for Medically Necessary Food. Click HERE to access the Tricare website reviewing coverage options.

To request coverage for ure-Na under your Medical Benefit as Medically Necessary Food, it is our understanding from working with Tricare that form 2642 needs to be submitted.

For more information about coverage for ure-Na, you can contact your Tricare regional contractor. You can find the telephone number for your regional contractor HERE


Indian Health Service
Indian Health Service typically follows the VA National Formulary (VANF). Ure-Na is available under the VANF as
UREA15GM/PKT/PWDR,ORAL. Please have the IHS pharmacist reach out to us with any questions.



For help with reimbursement, please call
1-844-980-9933 and leave a message to be called back by a reimbursement specialist.