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Medical vs. Pharmacy Benefits: The Differences in How Immunoglobulin (Ig) Therapy Is Covered

January 18, 2019

Immunoglobulin (Ig) replacement therapy is a lifesaving, lifelong treatment for many people with primary immunodeficiency diseases (PI), specifically those who are antibody deficient. For those who rely on this treatment, you need to know how your therapy is covered under your insurance. Is it part of your pharmacy benefit or your medical benefit? This is always important to understand, but it’s especially critical to know when there are supply issues that may prevent you from receiving your normal vial sizes for your dose.

Some patients have reported increased costs for their treatment due to vial sizes being unavailable and having to change certain elements of their infusions. Those who have their treatment covered under the pharmacy benefit could be faced with additional out-of-pocket costs for their treatment if their normal vial size is not available.

Each vial size has its own National Drug Code (NDC) in which pharmacy payers charge a co-pay for. So, if an incremental vial size is added that could trigger an incremental co-pay. For example, if you typically receive one 30-gram vial but it is not available so it is changed to one 20-gram vial and one 10-gram vial, you may be charged two co-pays. This is due to the NDC count increasing up to two from just the one NDC for the original 30-gram vial. Again, this scenario can happen when your treatment is processed under the pharmacy benefit.

When treatment is covered under the medical benefit, different vial sizes can trigger additional billing. For example, if you normally receive one 30-gram vial but it is changed to three 10-gram vials there would be no change in your co-pay since the three vials are the same size. If the 30-gram changed to a 20-gram vial and a 10-gram vial, however, this could lead to two co-pays due to the two different vial sizes.

In short, out-of-pocket expenses can potentially increase when vial sizes are changed. It is important to know whether your Ig therapy is covered as part of your pharmacy benefit or medical benefit. Once you are armed with that information, you and your provider can address how this affects you and determine what appropriate changes should be made if there are issues with the supply of certain vial sizes.

Questions? Submit your questions through Ask IDF: www.primaryimmune.org/askIDF.

This content should not be used as a substitute for professional medical advice. In all cases, patients and caregivers should consult their healthcare providers. Each patient’s condition and treatment is unique. The benefits and risks of any treatment should be discussed with the patient’s provider.

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