Understanding Insurance Coverage for Cross-Linking in the U.S.
Insurance coverage for cross-linking is a hot topic among the keratoconus community. Understanding all of the specifics can be confusing. In this blog, we answer your most frequently asked questions.
How do I know if my insurance covers cross-linking?
More and more insurance plans are now covering FDA-approved cross-linking. The only cross-linking procedure that is covered by insurance companies in the United States is the FDA-approved cross-linking procedure with Avedro’s Photrexa drug formulations.
How do I know if my doctor is performing FDA-approved cross-linking?
The easiest way to know if you are receiving FDA-approved cross-linking is to ask your doctor or check out the Physician Locator tool to see if he/she is listed.
Still not sure? Don’t be afraid to ask your doctor what device he/she uses for cross-linking and whether the procedure is FDA-approved or investigational. Ask if he/she is performing FDA-approved cross-linking with the Photrexa drug formulations manufactured by Avedro.
FDA-approved cross-linking uses the drugs and device manufactured by Avedro (these are the only cross-linking drugs and device that are FDA-approved and eligible for insurance reimbursement in the U.S.) –
In order to be eligible for insurance reimbursement, your procedure must consist of –
- Photrexa drug formulations
- The KXL® System
Avedro’s Photrexa drug formulations are:
- Supported with published, FDA reviewed, clinical data
- Manufactured in a world-class FDA registered facility
- Manufactured in compliance with FDA guidelines
- Packaged and controlled under highest quality GMP standards
What if my insurance company isn’t on the list?
This isn’t the end of the road! The journey towards reimbursement is a process, but more insurance companies are starting to cover FDA-approved cross-linking. The first step is to discuss your options with your doctor – (find a doctor performing FDA-approved cross-linking here)
- Speak with your doctor about filing an appeal. Depending on your situation, this appeal can be done before or after receiving treatment.
- Discuss financing options with your doctor.
Does insurance cover epithelium-on (epi-on) procedures?
Insurance does not typically cover products and procedures that have not received FDA approval. The only FDA-approved products for cross-linking are from Avedro, and are performed epi-off. Many insurance policies specify that the epi-off procedure is the only FDA-approved treatment for progressive keratoconus that is being covered, while the epi-on procedure is not.
Does insurance cover non-FDA approved products?
Generally, insurance does not typically cover products and procedures that have not received FDA approval. As an example, the Blue Cross and Blue Shield Association’s Technology Evaluation Center (Premera BCBS Technology Review) lists as part of their new technology evaluation criteria:
“1. The technology must have final approval from the appropriate governmental regulatory bodies.”