Does insurance cover FDA-approved cross-linking?
In a growing number of cases, the answer is yes. More and more insurance plans are now covering FDA-approved cross-linking. The latest list of insurers that have policies that cover cross-linking is shown below. The trend has been encouraging, and 33 insurance carriers now cover cross-linking, up from 3 at the beginning of this year.
Commercial Insurance Coverage for FDA-Approved Cross-Linking in the U.S.
*data on file
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.”
Does insurance cover epi-on procedures?
Generally, 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 performed epi-off. Many insurance policies have detail about the fact that the epi-off procedure is the only FDA approved treatment for progressive keratoconus that is being covered, while epi-on is not. See the examples below from Aetna and Blue Cross Blue Shield of MA.
“Aetna considers epithelium-off photochemical collagen cross-linkage using riboflavin and ultraviolet A medically necessary for keratoconus and keratectasia.
Aetna considers epithelium-on (transepithelial) collagen cross-linkage experimental and investigational for keratoconus, keratectasia, and all other indications.”
“Currently, the only CXL treatment approved by the Food and Drug Administration (FDA) is the epithelium-off method. There are no FDA-approved CXL treatments using the epithelium-on method.”
Which insurance companies cover corneal cross-linking for the treatment of progressive keratoconus?
The list of companies that are known to have policies that cover cross-linking is shown below.
|wdt_ID||Payer Name||Payer Region|
|2||Kaiser Permanente||AZ, CA, CO, DC, GA, HI, MD, NV, TX, VA, WA|
|3||Blue Cross Blue Shield FEP||National|
|4||Blue Shield of California||CA|
|5||Horizon Blue Cross of New Jersey||NJ|
|6||Blue Cross Blue Shield of Tennessee||TN|
|7||CareFirst Blue Cross Blue Shield||MD, DC, Northern VA|
|8||Blue Cross Blue Shield of Massachusetts||MA|
|9||Blue Cross Blue Shield of Alabama||AL|
|10||Regence Blue Cross Blue Shield||ID, OR, UT, WA|
|Payer Name||Payer Region|
*Coverage to begin on 12/15/2017. ** Coverage begin on 2/1/2018. This list is subject to change. It is not intended to be a directive, nor is it a suggestion about the likelihood of coverage or reimbursement. Please confirm with your individual carriers.
Frequently Asked Questions
I am interested in getting epi-on cross-linking or C3R. Does your program help get coverage for this?
Epithelium-off cross-linking with Avedro’s Photrexa® Viscous (riboflavin 5’-phosphate sodium in 20% dextran ophthalmic solution) and Photrexa® (riboflavin 5’-phosphate sodium ophthalmic solution) in conjunction with the KXL System is the only cross-linking procedure that has been approved by the FDA. Our program provides insurance support for the FDA-approved procedure using Avedro’s drug and device.
Contact your insurance provider prior to treatment to see if they currently provide coverage for corneal cross-linking. Aetna, Kaiser, Regence BCBS and BCBS Federal Employee Plan are among many commercial plans that are covering corneal cross-linking.
Avedro works directly with the doctor’s office and insurance company to help facilitate the insurance reimbursement process. Prior to getting the procedure, confirm with your doctor that they are performing Avedro’s FDA approved cross-linking procedure. You can find a list of physicians who are familiar with the cross-linking procedure using our locator tool.
Learn more about this outpatient procedure
View our Living with Keratoconus Patient Brochure.
Discover answers to the most common questions surrounding cross-linking
Visit the Patient FAQ Section to learn more.
It is estimated that...
1 Out of Every 2,000
persons in the general population have Keratoconus1
You can find more information from the National Keratoconus Foundation.
1. Kennedy R. H., Bourne W. M., Dyer J. A. A 48-year clinical and epidemiologic study of keratoconus. The American Journal of Ophthalmology. 1986;101(3):267–273. doi: 10.1016/0002-9394(86)90817-2.
Corneal cross-linking provides patients a much-needed option to treat this debilitating disease. Patients suffering from progressive keratoconus can now receive a therapeutic treatment that has been rigorously tested and approved."Mary Prudden, Executive Director for the National Keratoconus Foundation