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MYOBLOC IS AVAILABLE IN THREE VIAL SIZES FOR DOSING FLEXIBILITY1
MYOBLOC is ready to use and requires no mixing
3 single-dose vial sizes*
*For single-patient use.
- MYOBLOC must be refrigerated
(2° to 8°C or 36° to 46°F)
- Do not freeze or shake (pH=5.6)
- Protect from light
All orders are shipped in a specially-designed box packaged to maintain the required temperature between 36° and 46° F (2–8° C) during shipment.
MYOBLOC REIMBURSEMENT SERVICES
The MYOBLOC Reimbursement Services team provides
information and assistance as requested by the Healthcare Provider
Enroll in MYOBLOC Reimbursement Services using the Circle of Care™ Provider Portal.
GENERAL BILLING AND CODING ASSISTANCE
PATIENT-SPECIFIC INSURANCE BENEFIT INVESTIGATIONS
Provide a summary of benefits obtained from the insurance company to the Healthcare Provider
Benefits investigated for medical coverage and, where permitted under policy, specialty pharmacy coverage
- Specialty Pharmacy form is provided to the Healthcare Provider
Prior Authorization assistance
- Identification of payor requirements for approval
- Obtaining and providing the payors required form to the Healthcare Provider
GENERAL ASSISTANCE WITH CLAIMS AND APPEALS OF DENIED CLAIMS
Protocols for requesting appeals and/or review of claims
Answering questions from the Healthcare Provider’s office concerning claim denial
BILLING & CODING
|J-Code for MYOBLOC|
|J0587||JW Modifier - Required to be reported on a Medicare Part B drug claim for discarded drugs and biologicals. Providers must also document the amount of discarded drugs or biologicals in the Medicare beneficiaries’ medical records. For J0587, a billing unit is per 100 units of MYOBLOC. For example, injecting 5,000 Units into a patient would allow for 50 billable Units.|
|I-CM code for spasmodic torticollis (CD)*|
|ICD10 - G24.3||Spasmodic torticollis (CD)|
|CPT codes for chemodenervation of muscle(s), cervical spinal muscle(s) (eg, for spasmodic torticollis)†|
|CPT-64616‡||Chemodenervation of muscle(s), cervical spinal muscle(s); 50 modifier for bilateral injections|
|EMG codes from chemodenervation|
|95873||Electrical stimulation for guidance in conjunction with chemodenervation|
|95874||Needle electromyography for guidance in conjunction with chemodenervation|
|76942§||Ultrasonic guidance for needle placement imaging|
|National Drug Codes (NDCs)|
|VIAL SIZE||NDC NUMBERS‖|
|2,500 Units/0.5 mL||10454-710-10|
|5,000 Units/1 mL||10454-711-10|
|10,000 Units/2 mL||10454-712-10|
Note: Table contains possible appropriate codes for cervical dystonia.
* ICD-CM codes are based on the World Health Organization (WHO) International Classification of Diseases, 10th edition. Solstice Neurosciences, LLC assumes no liability for information contained herein. Solstice claims no ownership or other interest in the ICD-CM codes. ICD-CM codes are provided herein for reference only. Only a patient’s Healthcare Provider may determine the appropriate ICD-CM code.
† CPT® codes are copyrighted property of the American Medical Association (AMA). Solstice assumes no liability for any of the information contained herein. Solstice claims no ownership or other interest in the CPT codes. CPT codes are provided herein for reference only and are not intended to convey any endorsement or sponsorship by, or affiliation with, the AMA.
‡ CPT code 64616 is the usual CPT code for administration of MYOBLOC for chemodenervation of parotid and submandibular salivary glands, bilateral. Other administration codes maybe appropriate.
§ CPT code 76942 is the CPT code for ultrasonic guidance for needle placement imaging. To be listed separately in addition to code for primary procedure.
‖ Please note that for billing purposes, some payers may require an 11-digit code based on the NDC number. Therefore, a zero must be entered into the 6th position (eg, “10454-0710-10”). This is consistent with the Red Book and First DataBank listings.
MYOBLOC PATIENT PROGRAMS
For eligible patients who need financial assistance in obtaining MYOBLOC treatment, we offer the following patient programs:
MYOBLOC Co-pay Program
The MYOBLOC Co-pay Program assists eligible patients with cervical dystonia with their out-of-pocket expenses associated with MYOBLOC and the related administration expenses. With no limit per injection, eligible patients may receive up to $4,000 per year of assistance with permitted out-of-pocket expenses.1
Patients who are 18 years or older, diagnosed with cervical dystonia (G24.3), a legal US resident, who have commercial insurance coverage according to the terms and conditions of the program and are NOT enrolled in a government insurance plan (eg, Medicare, Medicaid, TRICARE®, and other federal- or state-funded programs).2
Once eligible for participation, the patient’s eligible out-of-pocket expenses may be paid directly to the site of care (administering office or pharmacy) on the patient’s behalf, or to the patient as a reimbursement for out-of- pocket expenses they paid to the site of care.
Irrespective of who will receive the co-pay payment, the site of care must first file a claim for MYOBLOC and the related injection-administration expenses with the patient’s private insurance carrier(s). An Explanation of Benefits that shows payment for MYOBLOC and the related injection expenses is required with supporting evidence to establish out-of-pocket expenses before any such reimbursement is authorized by the MYOBLOC Co-pay Program [See Reference 1 for Michigan, Rhode Island, and Minnesota residents].
Upon approval into the program, eligible costs for the patient’s MYOBLOC injections may be submitted for payment. The program administrator will verify that the costs are eligible for payment. Payment for eligible costs will be issued to the site of care via a virtual credit card number within two business days of the receipt of information validating eligible out-of-pocket expenses.
If the site of care requires a check reimbursement, that check will be issued and mailed within 3-4 weeks. Any pharmacy using the Co-pay Program may use the patient’s card ID, Rx and BIN to process and receive payment on claims.
Terms and Conditions for Healthcare Providers
1. This offer is valid for commercially insured patients only and is good for use only with a MYOBLOC prescription at the time the prescription is filled or after the product is administered to the patient. 2. Depending on insurance coverage, eligible insured patients may pay no more than zero dollars ($0) for MYOBLOC and the administrative services associated with MYOBLOC, up to a maximum savings limit of four thousand dollars ($4,000) per year. Patient out-of-pocket expense may vary. 3. This offer is not valid for patients enrolled in Medicare, Medicaid, or other federal or state healthcare programs, or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this Program if they are Medicare-eligible and enrolled in an employer-sponsored health plan or medical or prescription drug benefit program for retirees. 4. The offer is valid for one (1) year. 5. Supernus reserves the right to rescind, revoke, or amend this offer without notice. 6. Offer good only in the USA, including Puerto Rico, at participating pharmacies or Healthcare Providers. 7. Void if prohibited by law, taxed, or restricted. 8. Residents of Michigan, Rhode Island, and Minnesota are not eligible for assistance with payment for injection or injection guidance-related costs, but may receive assistance with MYOBLOC. 9. This Program is not transferable. The selling, purchasing, trading, or counterfeiting of this Program is prohibited by law. 10. This Program is not insurance. 11. By redeeming this assistance, you represent that, to the best of your knowledge, the patient is eligible to participate in the Program and that you understand and agree to comply with the terms and conditions of this offer.
*Patients are free, at any time, to switch Healthcare Providers, practitioners, pharmacies, commercial insurers, or suppliers without affecting continued eligibility for assistance. If patients begin receiving benefits from a government program, they would become ineligible for the Co-pay Assistance Program for MYOBLOC.
Submitting an application for assistance does not guarantee funding will be available. If financial assistance is awarded, it will be provided on an annual basis. Applicants must reapply for assistance each year. Funding in any subsequent year(s) or timeframes is not guaranteed. The Co-pay Assistance Program for MYOBLOC may be modified or discontinued at any time. NOTE: Reimbursement services are available only for those patients being treated with MYOBLOC for a therapeutic condition for which there is a reasonable expectation of reimbursement from a third-party payer. Physicians are responsible for identifying the clinical indication and documenting medical necessity for use of MYOBLOC. Questions regarding the clinical use of MYOBLOC should be directed to 1-888-461-2255, Option 2.
Patient Assistance Program
MYOBLOC is available at no charge to eligible patients who are approved for the Patient Assistance Program.
- Patients for whom MYOBLOC is prescribed by a licensed physician to treat cervical dystonia
- Patients who have no health insurance benefits for MYOBLOC
- Insured - No benefits
- Patient cannot otherwise afford MYOBLOC therapy
- Patient is a legal United States resident
- Patient is injected with J-Code J0587 accompanied with ICD-10 code G24.3
For patients who are approved for the Patient Assistance Program:
- MYOBLOC is provided at no charge
- MYOBLOC is shipped directly to the Healthcare Provider marked for patient use
- Qualified patients are eligible to receive MYOBLOC injections for two (2) dates of services provided that they do not subsequently gain health insurance benefits
- Patient may re-apply for additional dates of service
- Patient is responsible for any charges related to Healthcare Provider
Solstice Neurosciences, LLC (“Solstice Neurosciences”), a wholly-owned subsidiary of Supernus Pharmaceuticals, sets the criteria for the Patient Assistance Program. Acceptance into the program at any time is not a guarantee that patients are entitled to receive assistance indefinitely.
Solstice Neurosciences reserves the right at any time, and without notice, to modify or discontinue any or all of the aspects of the Program; or to terminate assistance under the Program at any time.