In general, there are two ways that LARC methods can be covered by patients’ health insurance plans: as a medical benefit or a pharmacy benefit.
When a LARC method is covered as a medical benefit, a provider:
- Buys the LARC method directly from the manufacturer or a designated pharmacy or specialty distributor.
- Bills the patient’s insurance carrier for the LARC method and insertion procedure.
This is commonly described as “buy and bill.”
When a LARC method is covered as a pharmacy benefit:
- A pharmacy or specialty distributor bills the patient’s insurance carrier directly for the LARC method.
- A provider bills the patient’s insurance carrier for related procedures and services.
Each of these models for purchasing LARC methods has benefits and drawbacks. In general, the medical benefit approach may facilitate offering same-day placement of LARC methods, but may require a significant capital outlay. In general, the pharmacy benefit approach reduces the need for upfront capital, but may make it difficult to provide same-day placement. Patients and providers can both advocate for the model that will work best. Specifically, providers can advocate that both billing options should be available to them by giving an insurance plan medical director information regarding the benefits and safety of same-day placement of LARC methods [10-12].
Whether LARC methods for Medicaid enrollees must be billed by a pharmacy or stocked and billed by a provider upon insertion varies by state. Providers should consult their Medicaid provider manual(s) for state-specific coverage details.
When the LARC method is covered as a medical benefit
IUDs may need to be purchased directly from the manufacturers or through a distributor, depending on the type of device. Implants can be purchased from the specialty pharmacies CVS Caremark or Curascript. When purchasing LARC methods, providers may be able to realize benefits from volume discounts, 90-day net terms, and other payment options.
LNG-IUS - Mirena & Skyla
Bayer offers a “buy and bill” option via the Women’s Health Care Support Center to help providers stock its two LNG-IUS methods (Mirena® and Skyla®) in advance of patient request. They provide 90-day net terms, credit card or e-check payment, and tiered discounts. Providers can place a wholesale order by registering and ordering online, completing and faxing a wholesale order form, or calling 1-866-647-3646 at any time.
The Bayer online system provides support for ordering products, checking account status, making payments, and accessing any needed forms. Providers will need an email address, NPI number, and a clinician’s state license number in order to register for the online system. A validation form is issued at the end of the registration process, which must be completed and returned to the fax number provided; access to the online system is granted within 48 hours. If the address on the clinician license is different from the shipping address, providers will also need to provide a letter of affiliation.
For wholesale orders placed online, providers have the option to pay for the entire order, make a partial payment, or be invoiced later. Wholesale orders using the paper form provide the option to pay for the entire order or be invoiced later.
LNG-IUS - Liletta
The only distributor of the Medicines360 LNG-IUS, Liletta™ is ANDA. ANDA offers a “buy and bill” option to help providers stock Liletta in advance of patient request. They provide 90 day net terms, credit card payment, and tiered discounts. Providers can place a wholesale order by registering and ordering online or calling 855-545-3882 from 8 am to 8 pm Eastern time, Monday through Friday.
The online system allows providers to order products, check shipments, make payments, access forms and obtain reimbursement assistance. Providers will need an email address, NPI number, copy of the clinician state license and DEA number in order to register. To access 340B pricing, a provider will also need to supply an active 340B number and be registered with Apexus. No letter of affiliation is required when the clinician license and shipping address are in the same state. New accounts are activated within 48 hours. Your practice may qualify for a line of credit; ask the ANDA representative after the account has been activated. Orders placed during business hours will be shipped for next day delivery.
For practices placing their first order of fewer than 5 Liletta devices, ANDA is offering a one-time Ready Stock program with 120 day terms.
Currently the only manufacturer of a copper IUD is Teva, which offers “buy and bill” via ParaGardDirect to help providers stock copper IUDs (ParaGard®) in advance of patient request. This service allows 90-day net terms (despite the application stating they offer only 30-day net terms); payment by credit card, check, or a line of credit; and tiered pricing discounts. Providers can place a wholesale order by applying for an account and ordering online, or calling ParaGardDirect at 1-877-727-2427 between 8:30 a.m. to 8:00 p.m. ET, Monday through Friday.
To apply for an account, practices will need an email address, a DEA or Health Industry number, and a copy of a clinician’s state license. If the address on the clinician license is different from the shipping address, the provider will also need to submit a letter of affiliation.
Some providers may not immediately be eligible for a line of credit with ParaGardDirect when first opening an account; however, most will qualify for one after establishing a credit history with the company. The payment terms remain the same regardless of how invoices are paid.
Currently the only implant available is manufactured by Merck (Nexplanon®), which offers two “buy and bill” options via CuraScript and CVS Caremark to help providers stock the implant in advance of patient request. Both specialty distributors provide 90-day net terms, credit card payments or lines of credit, and a 2% discount for orders paid with a credit card or within 90 days if invoiced. Neither distributor offers volume discounts for the implant. Providers may request assistance with determining which distributor to use and be directly connected to both distributors by calling Merck at 1-877-467-5266 from 8:00 a.m. to 8:00 p.m. ET, Monday through Friday. Both distributors require that any providers purchasing implants must first complete the required Merck training program.
To order from CuraScript, you must first establish an account. Call 1-866-844-0148 and the Nexplanon team will help you apply for an account. A provider will need an email address, DEA number, federal tax ID number, a clinician’s state license number, and a student ID number from the Nexplanon training certificate to complete the application. Bank references are also required if a provider is seeking a line of credit. To get access to 340B pricing, providers must supply their active 340B number. Curascript will confirm your access to 340B prices, which may take 5 to 15 days. Once an application is complete, an account is usually set up within 48 hours. To place an order using a CuraScript account, providers should call 1-866-844-0148 or order online. Orders received by 6:00 p.m. ET are processed that day and shipped second-day delivery. Overnight shipping is also available upon request.
To order from CVS Caremark, providers should contact a customer service representative at 1-866-318-3492 and request a “Buy and Bill Order Form.” For wholesale purchases, a provider will need to complete a wholesale agreement and a letter of affiliation for each clinician in the practice. To make either an individual or wholesale purchase, a provider will need an email address, NPI number, a clinician’s state license number, and a student ID number from the Nexplanon training certificate. Orders received by 4:00 pm ET are processed that day and shipped second-day delivery. Overnight shipping is also available upon request.
When the LARC method is covered as a pharmacy benefit
LARC methods are sometimes covered as a pharmacy benefit, which may make stocking the methods ahead of time challenging. It can take up to seven days to receive products ordered via the various specialty pharmacy programs (SPPs).
All three distributors of the Bayer LNG-IUS methods —CVS Caremark, Prime Therapeutics, and Walgreens—offer an SPP option. Providers should complete the Specialty Pharmacy Prescription Request form and include patient authorization when sending the completed form to the chosen pharmacy distributor. The Mirena website includes detailed instructions for completing these forms.
The Medicines360 LNG-IUS is available through Accredo Specialty Pharmacy. Call 877-ACCREDO to place an order. Each order requires a copy of the patient’s insurance card, basic patient demographics, and a prescription. If your patient plans to use the Liletta Patient Savings Program (see the section on patients with commercial coverage), supply the Liletta card number along with the order. It may take up to 7 days to verify a referral; once complete, the product is sent to the practice by overnight mail.
Women’s Health Access Solutions is the SPP for the copper IUD. A provider must complete the Patient Referral and Patient Authorization forms. In order to have the copper IUD delivered directly, a provider should select “Prescriber office will use Specialty Pharmacy” under the form section “How do you intend to obtain ParaGard?”
Prescription orders may be placed for individual patients using the same distributors as for wholesale. Send the prescription using the CuraScript Benefit Verification Form (1-866- 844-0148) or the CVS Caremark Service Request Form (1-866-318-3492).
Patients purchase LARC methods using a payment plan
Patients wishing to use an implant or copper IUD are able to arrange staggered payment plans with credit cards through Curascript or Teva Women’s Health, respectively. For an implant, a patient may choose to make three or six monthly payments. For a copper IUD, a patient may choose to make four or 12 monthly payments. In both cases, patients must provide a clinician’s name, address, phone, and fax number to place an order, and the LARC method is shipped directly to the clinician. For details about these programs, see the section on working with self-pay patients. Other LARC methods do not have staggered payment plans available.