Why is a benefits investigation important?
XOLAIR Access Solutions conducts a benefits investigation (BI) to help you better understand your patient's health insurance plan coverage for the costs associated with treatment. The BI can also determine if a prior authorization (PA) or patient assistance might be needed.
There are 3 possible outcomes of a BI:
- Treatment is covered
- PA is required
- Treatment is denied
To begin with XOLAIR Access Solutions, you must complete and submit a Statement of Medical Necessity (SMN) form and have your patient complete and submit a Patient Authorization and Notice of Release of Information (PAN) form. To request a BI, be sure to check the appropriate box on the SMN.
This description of a BI is for informational purposes only. XOLAIR Access Solutions makes no representation or guarantee concerning reimbursement or coverage for any service or item.
XOLAIR Access Solutions can help your practice identify if a prior authorization (PA) is needed and offer support as you obtain it for your patient. All we need to begin are a completed and signed Statement of Medical Necessity (SMN) form requesting our assistance with the PA as well as a signed and dated Patient Authorization and Notice of Release of Information (PAN) form.
XOLAIR Access Solutions can help you as you submit the required PA forms and documentation. If the PA is not granted, XOLAIR Access Solutions can work with you to determine next steps. Tips like this can be found in Forms and Documents.
XOLAIR Starter Program
While coverage is being determined, the XOLAIR Starter Program might be able to help
The XOLAIR Starter Program provides XOLAIR use at no charge for up
to 12 weeks for eligible patients still waiting for their insurance
plans’ coverage decision.
To get started, complete the XOLAIR Starter Program section of the Statement of Medical Necessity (SMN) form, remembering to check the box next to the XOLAIR Starter Program Prescription.
Patients eligible for the XOLAIR Starter Program
- Patients who are using XOLAIR for an approved indication
- Insured patients who have not received a coverage decision for XOLAIR within 7 days
- New XOLAIR patients or patients who have not been on XOLAIR within the last 12 months
Once patients meet the eligibility criteria, their medicine can be shipped within 48 hours.
When XOLAIR is authorized for a specific and limited period of time, it generally requires recertification for coverage of continued treatment. XOLAIR Access Solutions can help you obtain recertification for your patients on XOLAIR. You can also work with the patient’s specialty pharmacy to have the treatment recertified. If the health plan approves the request, XOLAIR can be dispensed to your patient through the specialty pharmacy. If the health plan denies the request for recertification, an appeal may be filed.