Medicare/Medicaid in the U.S.
Medicare, the U.S. federal health insurance program for people age 65 and over, people under age 65 with certain disabilities, and people of all ages with End Stage Renal Disease, in all 50 states has determined that Immunocal is eligible for coverage and reimbursement when certain requirements are met. Medicare covers Immunocal when it is prescribed for tube feeding only and pays for no more than one month’s supply of nutrients at a time. Complete coverage requirements are explained in the Medicare National Coverage Determinations Manual, Chapter 1 and the Medicare Benefit Policy Manual, Chapter 15.
Medicaid, the joint federal and state-funded program for certain categorically eligible low-income individuals and families, determines coverage and reimbursement for Immunocal on a state-by-state basis. Please see the chart below to determine whether Immunocal is eligible for coverage under a particular state’s Medicaid program. Please note that many state Medicaid programs that cover Immunocal require prior authorization. Please verify individual state Medicaid rules for specific coverage and reimbursement requirements.
Obtaining product: For both Medicare and Medicaid coverage, Immunocal must be prescribed by a licensed physician. The prescription must be taken to a pharmacy to be filled. If covered in that particular state, the pharmacy will order Immunocal from their national wholesalers. These wholesalers get the product from Immunotec’s Medical Division.
Immunotec’s Medical Division: Product for Medicare and Medicaid is handled by Immunotec’s Medical Division.
For more information: Please contact Immunotec Medical Division.
To place your order
By e-mail: medicalorders@immunotec.com
By telephone: 450-424-9992 ext. 2373
By fax: 450-424-9993 / medical department
Private Insurance Coverage
Individuals should contact their private healthcare insurance company to inquire whether Immunocal is covered if prescribed by their healthcare professional. Reimbursement will follow your insurance company’s usual protocol.
Reimbursement by State
Please see the below chart for general information. Please note, Medicaid program requirements are subject to change. Healthcare providers and patients should check with their state Medicaid agency to obtain current coverage and billing requirements to ensure compliance with state requirements.
Covered - Often priced by individual claim, frequently needs prior approval
- Colorado
- Connecticut
- Indiana
- Maine
- Massachusetts
- Michigan
- Minnesota
- Missouri – may need “exception” form
- Nebraska
- New Jersey
- New York
- North Dakota
- Ohio
- Oregon
- Vermont
- Virginia – AIDS only
- Wisconsin – AIDS, wasting, Cystic Fibrosis
- Wyoming
Reimbursed by calorie content
- Arizona
- New Mexico
- Illinois – AIDS & Cancer only
- Louisiana – may need “Exception” Form and must represent 70% of calorie intake some cases under 21 would cover orally
- Washington
- Idaho – Children only for oral and reimbursed by calorie
Coverage follows Medicare Guidelines - Tube feeding only
- Hawaii – also reimburses by calorie as well
- Iowa – Children only for oral and also there is disease restrictions
- Kentucky – Might try “Exception” Form
- Maryland – Disease restrictions
- Montana
- South Carolina
- South Dakota
- Texas – May cover children orally
- Utah
- Washington DC
Immunocal code not covered
- Alaska
- Alabama – Children may be given special consideration
- Arkansas – Children only
- California – TAR form
- Delaware
- Florida
- Georgia – Oral is only children under 21
- Kansas – Reimbursed by calorie as well
- New Hampshire
- Mississippi – May cover children orally
- North Carolina
- Nevada
- Oklahoma – Children may be given special consideration
- Pennsylvania
- Puerto Rico
- Rhode Island – May cover children orally, disease restrictions
- Tennessee
- West Virginia
All Medicare/Medicaid business is handled by the Medical Division’s Distribution Group. Since it is government reimbursement it must be handled this way so as not to be in violation of anti-kickback statutes.
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