neovisc_reimbursementassistance info_020513

Reimbursement Assistance Information
Sterile Sodium Hyaluronate Solution 1.0%
This list is an example of some of the insurance companies who should cover NeoVisc®. If your insurance company is not
on this list, please contact them with the following information.
1. Identify NeoVisc® first by NAME. Most insurance companies should recognize NeoVisc®.
2. If NeoVisc® is not recognized by name: Ask the customer service representative to check under the category “viscosupplementation” or
“synovial fluid replacement” - NeoVisc® belongs to this class of devices.
3. If viscosupplementation and NeoVisc® are not recognized: Try providing a Pseudo-DIN or PIN provided by the Atlantic Pharmaceutical Services
(APSI) 96599991 or 96599999. NeoVisc® is approved by Health Canada as a medical device and, as such, does not have a Drug
Identification Number (DIN), only a Pseudo-DIN or PIN.
4. Should the drug card reject NeoVisc®, this does NOT mean that the patient is not covered. Patients may be required to fill out an “Insurance
Claims” form to apply for reimbursement under the extended health portion of their plan. An accompanying physician letter would enhance
reimbursement.
5. If after following guidelines 1-4 and reimbursement is still denied, then the next step is a physician letter addressed to the Human Resources
Department (Employee Benefits Manager) of the Employer whose Benefits Plan the patient is covered under. It is recommended that
the patient personally deliver this letter to the Human Resources Department – Benefits Plan Manager. The content of the letter should briefly
summarize the patient’s medical condition and why NeoVisc® is necessary for their personal and professional well being. The Employer
Benefits Plan Manager can then contact the Insurance Company and direct them to reimburse the patient.
Company
Commments
Canadian Forces Health Services
• Covered under health benefits
Desjardins
1-866-647-5088
• Treated as a drug for coverage (e.g. 80%, 90%, 100%)
The Empire Life Insurance Company
1-800-267-0215
• NeoVisc® - Viscosupplement injections – Indicate which joint
The Great-West Life Assurance Company
1-800-957-9777
• NeoVisc® should be recognized by name
• Treated as a drug coverage (e.g. 80%, 90%, 100%)
• Make reference to: Pseudo-DIN or PIN# 96599991 and #96599999
Green Shield Canada
1-888-711-1119
• Covered under extended health benefits – Viscosupplement Injection
Industrial Alliance Life Insurance Company
1-877-422-6487
• Not a drug or medical device, recognized by class and by name
• Special Product
Manulife Financial
1-800-268-6195
• NeoVisc® should be recognized by name
Medavie Blue Cross
1-800-667-4511
• Mention NeoVisc® is not a drug
• Recognized as a synovial fluid replacement / viscosupplement
The Non-Insured Health Benefits (NIHB) Program of the
First Nations and Inuit Health Branch (FNIHB)
• Exceptional product status if the criteria are met
Ontario Blue Cross
1-800-234-8881
• NeoVisc® or Synovial Fluid Replacement
SSQ
1-800-565-4550
• Treated as a drug for coverage (e.g. 80%, 90%, 100%)
Standard Life – Calgary
403-296-9400
• Viscosupplement-Injections (not drug)
• Note: max 3 injection per limb/lifetime
Standard Life – Ontario
1-800-465-2581
• Viscosupplement – injection (not a drug)
Sun Life Financial
1-800-361-6212
• Mention that NeoVisc® is an INJECTION
• Treated as a drug coverage (e.g. 80%, 90%, 100%)
• Make reference to: Pseudo-DIN or PIN# 96599991, #96599999 & #00990004
The Chamber of Commerce
1-800-665-3365
• Patient to submit a request for coverage in writing, include Pseudo-DIN or PIN
Veterans Affairs Canada
Workplace Safety and Insurance Board (WSIB)
• Covered under ID# 96599991 and # 96599999
• Patient pays direct and submits claim to be assessed on an exception basis
• Recommended submission: physician letter, prescription & invoice for NeoVisc®
Please Note: Insurance Companies may cover “viscosupplements” but the patient’s policy may not, even though it is through the same Insurance Company.
Health Canada Medical Device License# 5442
Pseudo-DIN/PIN 96599999
Three (3) doses of 2 mL
Pseudo-DIN/PIN 96599991
Single does (6 mL)
Tribute Pharmaceuticals Canada Inc.
544 Egerton St., London, ON, N5W 3Z8
www.tributepharma.com
M-MK-25 140102