Medicare Insurance coverage for Xeloda

My doctor switched me from Faslodex to Xeloda due to growing mets in my liver (from breast cancer). I have medicare and was shocked to see that neither medicare nor my supplemental insurance (Anthem Blue Cross) would cover the cost ($2,000 per month). I am in Mexico often and can get the drug for $1,400 there but it is still cost prohibitive. I am trying to get Genentech to cover it for me but do not know yet if it will....does anyone have or know of a medicare supplement that covers Xeloda?

Report post

15 replies. Join the discussion

Xeloda is covered through your Medicare Part B coverage. You will probaby have to get it from a mail order pharmacy. Your doctor's office should know how to do this. Xeloda is treated the same as an IV chemo through Medicare even though it isn't.

Report post

I hope you have part B. And a good drug coverage, aside from Medicare. I know when I was on xeloda, it took some sort of dispensation of my secondary to cover the medicine. Don't know why, just know it eventually was covered. If you can't convince your biller to work on it, I would call the company that makes it and see what they have to say. They want their medicine used and many times can give some information about how to go about doing it.

Report post

I have part B Medicare and both the pharmacy and they denied that they would cover Xeloda period! The pharmacy spent a lot of time with Medicare trying to figure out a way to make it work and was told there was no way they would cover.

I also called Medicare and was given the same story. ...perhaps this is a new thing with them.

I talked to Anthem Blue Cross and was told that they did not cover it (they are my secondary) either. I will talk to both of them again. In the meantime my doctor is trying to get Genentech to send it to me....

Report post

Try calling the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for your state. You can find the number on the Medicare.gov website. Xeloda should be covered under Prescription Drugs (Outpatient). Everything I've read says it is covered.

Report post

Medicare Coverage of XELODA® (capecitabine)

XELODA is the first oral anti-cancer drug approved by the FDA for treatment of both colorectal cancer and metastatic breast cancer. XELODA is also approved for Dukes’ C (Stage III) colon cancer. It is a “prodrug” of 5-fluorouracil.

CONFUSION AT THE PHARMACY COUNTER:
Medicare Part B generally covers certain oral anti-cancer drugs, including XELODA, as equivalent replacements for covered injectable anti-cancer treatments. With the implementation of Medicare Part D, Medicare beneficiaries enrolled in prescription drug plans have access to additional oral and self-injectable anti-cancer drugs. This has created confusion at the pharmacy since XELODA is an oral chemotherapy agent and might be confused for a Part D covered product. However, because XELODA has no other approved indications besides cancer treatment, XELODA continues to be eligible for coverage only under Medicare Part B.

Action: Assure that dispensing pharmacists understand that Xeloda is eligible for coverage under Part B and recognize new reject codes for Part D drug claims.


BILLING MEDICARE FOR XELODA:
Xeloda retail prescriptions for Medicare beneficiaries must be filled by a participating Medicare supplier and claims filed with the Medicare Durable Medical Equipment Medicare Administrative Contractor (DME MAC) serving the patient’s state of residence. Part B claims are filed either on a CMS-1500 claim form or electronically.

NEW PART D DENIAL CODES:
CMS guidance provided to the Part D plans includes the following directives on oral anti-cancer drug coverage:

“To the extent that a Part B-covered oral anti-cancer drug has no other medically accepted indication besides cancer treatment, Part D plans should not include these drugs on their formularies because of Part B coverage. 1”

The Centers for Medicare and Medicaid Services (CMS) provided further guidance to the Part D plans in an August 15, 2006, memorandum entitled: “Part D Claims Messaging Requirement.2” In it, CMS advised that Part D plans should implement an appropriate strategy addressing Part D claims rejections that achieves the goal of the industry consensus on messaging. CMS strongly encouraged plan adoption and use of the standardized approach in the NCPDP guidance as issued in the 5.1 Editorial Document. The new NCPDP 5.1 reject codes are identified as follows:

(A5) Drugs are excluded from Part D coverage
(A6) Drugs are covered under Part B coverage for a beneficiary3

Code A6 applies to XELODA claims filed with a Part D plan.

For further information, please contact the ONCOLINE Reimbursement Hotline at 800-443-6676.

References: 1. Medicare Part B versus Part D coverage issues http://www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/BvsDCoverage_07. 27.05.pdf (page 10) Accessed September 13, 2006.
2. Part D claims messaging requirement. http://www.cms.hhs.gov/PrescriptionDrugCovContra/downloads/MemoStandardized MessagingPolicy_08.15.06.pdf Accessed September 13, 2006.
3. Part D claims messaging requirement. http://www.cms.hhs.gov/PrescriptionDrugCovContra/downloads/MemoClaimsMessag ingRequirement_05.22.06.pdf Accessed September 13, 2006

http://www.pharmacistelink.com/news/2007/07/03_roche2.doc

Report post

Also I found these codes for Xeloda on the CMS website -

J8520 Capecitabine, oral, 150 mg ROCHE 00004-1100-20 Xeloda 150 MG

J8520 Capecitabine, oral, 150 mg PHYSICIANS TOTAL CARE 54868-4143-02 Xeloda 150 MG

J8521 Capecitabine, oral, 500 mg ROCHE 00004-1101-50 Xeloda 500 MG

The first number with "J" is the CMS code.

Report post

Thanks for all the help...I spent about an hour on the phone with a medicare person today...gave him the codes which he could not find even going to different data bases...read him all the info you all have sent...he found someone to help and located a code from 2006 for Xeloda which he was checking out when we had a power failure and I lost the connection...very frustrating. I have forwarded all this info to my doctors office and will continue trying to get my answers. Thank you so much for the info...I'll be working on this again tomorrow and hopefully will not have the frustration with the phone (a transformer went out across the street) *sigh*

Report post

I also thank you for all this information. This coverage issue came up today at the one's office & The nurse tried to tell us my mom was not covered because her Part D was not in effect. I told her it was covered under Medicare part B and she is supposed to get back to me if she has problems with the authorization. Now, I am well armed if there is a problem. Very timely and helpful information.
You girls are the best!
Maria

Report post

Thank you blindsided in New York! That's exactly the kind of hassle I was given and why the clerk spent a lot of time with Medicare and then my secondary insurance. I remember now that she finally told them it was FU5 and if I were to have to come in and get the infusion rather than the pill form of this cancer drug, it would cost them thousands more. I think that might have been enough for somebody to dig further, because it went through.
Texasdj, where have you been, or have I just missed your posts? I have to limit my time on this site because life (thank God) does go on. I will take this info back to the billing at the large university that I went to when prescribed the xeloda, and make sure they have J8520 for the 150mg. and J8521 for the 500 mg coded in . In fact they were going to give me all 150Mg. because someone coded only it in!
But first I'll see if they can tell me the code. These things shouldn't be secrets. I had trouble at one time, at one place because the girl didn't have the medicare code for metastasized breast cancer is it 174.9? I forget now although I should have written it down. Anyway, she said she couldn't bill it until I got the code for her. code. Unbelievable!
jo823, I can't believe you had that outage. That's exactly the kind of snafu that happens to me. An, one question, was the person you were talking to named Todd? I would be more inclined though to take all that info to the billing office and make them spend the time with the clerical aspects. They need to know this info and the code for the rest of the people coming behind. Also I know the drug company knows this code! I think that is where the clerk eventually got it for me.

Report post

I am taking Xeloda and I have medicare part B and BC/BS. My Onc. told me from the first day they would have to order it from a specialty medicine company in another town. I would not be able to get it through my normal pharmacy. They send it to me by FEDEX and has to be ordered each time, no refills.

You probably have other medical bills that haven't been filed correctly and therefore not paid if the clerk doesn't know the code for MBC. If the code is right, medicare will reject it.

Report post

It helps if you have a good pharmacy department to help you. I was on Xeloda for almost 2 years and the pharmacy at our local Walgreens handled everything for me-and it is covered under Medicare part B. Hope everything works out for you.

Report post

I am currently on xeloda. I get it by CVS Caremark's central mail pharmacy. It is covered by Medicare. I also have blue cross/blue shield of Georgia for my supplemental. Keep on pursuing this, it is covered!

Report post

Thank all of you...I copied all the replies and sent them to the new person (who is there to help patients but hadn't had enough experience with this drug) at my doctors office A few days later I received a call from CVS Caremark telling me all is covered and that they are putting me on an automatic refill for Xeloda for as long as it is covered by Medicare/Anthem Blue Cross...I got the call on New Years Eve so I am taking it as a sign that this year is going to be a good one. Again, thank you for all the replies...without them I would still be dealing with pharmacies that didn't know how to bill and calling the wrong medicare people, etc. Now I will have my meds and hopefully not a lot of bad side effects ...I am a happy camper!

Report post

The things we have to go through just to get are DARN medicine just amazes me. Is it NOT enough that we're dealing with being sick?? I'm SO happy you were given so much great information. My gosh, what the heck would we do without each other?? I don't even want to think about it. I was given the exact same business about herceptin. I had to pay a co-pay of $400.00 per treatment. Genentech helped me with the costs. I hope you can get this figured out and get your meds covered. Hang in there!

Suzy

Report post

@Suzy

We must have been posting at the same time. My meds are now covered for Xeloda which was a great start to my new year. I am truly grateful to the members of this site for their help...by sending on all the information that was provided here my doctors assistant was able to get 100% coverage...hopefully they won't change any rules or coverage....the sad thing is that without this site I would probably still be dealing with the problem and there must be many other folks out there that don't know how to get through the red-tape

Report post

This discussion is closed to replies. We close all discussions after 90 days.

If there's something you'd like to discuss, click below to start a new discussion.

Things you can do

Advertisement

Advertisement

Discussion topics

Community leaders