Does insurance cover Ycanth and how are offices reimbursed for it?

Insurance Coverage and Reimbursement for YCANTH (Cantharidin 0.7% Topical Solution)

Most insurance plans will cover YCANTH (cantharidin 0.7% topical solution) for the treatment of molluscum contagiosum in patients 2 years and older, though coverage details and reimbursement rates vary by plan type.

Insurance Coverage Overview

YCANTH is an FDA-approved drug-device combination product containing cantharidin 0.7% topical solution for the treatment of molluscum contagiosum 1. As with most prescription medications, coverage varies by insurance type:

• Private Insurance: Most private insurance plans will cover YCANTH, but with varying cost-sharing requirements:

  • Patients may be responsible for copayments, coinsurance (typically 20-35% of list price), or deductibles 2
  • Some plans may require prior authorization
  • Coverage is typically better in states with mandates for such services 2

• Medicare: Medicare Part D beneficiaries will have coverage subject to:

  • Annual deductible ($405 in 2018 standard plan)
  • 25% coinsurance after meeting the deductible
  • Higher costs in the coverage gap ("donut hole") 2

• Medicaid: Generally provides the most comprehensive coverage:

  • Nominal copayments ($1-$5) if the medication is on the state's preferred drug list
  • Coverage varies by state, but medical necessity can be established through provider documentation 2

Office Reimbursement Process

Medical offices receive reimbursement for YCANTH through:

1. Procedure Billing: Using appropriate CPT codes for application
2. Medication Billing: Either through:
   • Buy and bill (office purchases medication and bills insurance)
   • Specialty pharmacy distribution (patient's pharmacy benefit)

Reimbursement amounts depend on:

• Insurance contract rates
• Geographic location
• Provider specialty status

Maximizing Coverage and Reimbursement

To optimize coverage and reimbursement:

• Document Medical Necessity: Clearly document the diagnosis of molluscum contagiosum and medical necessity for treatment

• Prior Authorization: Be prepared to complete prior authorization forms, which may require:

  • Confirmation of patient age (≥2 years)
  • Documentation of diagnosis
  • Number of lesions and affected areas

• Coding Accuracy: Use appropriate ICD-10 and CPT codes for molluscum contagiosum treatment

• Patient Assistance: For underinsured patients, investigate manufacturer assistance programs

Common Pitfalls to Avoid

• Inadequate Documentation: Failure to document medical necessity may result in claim denials
• Incorrect Coding: Using inappropriate procedure codes can lead to payment delays
• Ignoring Prior Authorization: Skipping required prior authorizations often results in denied claims
• Billing Issues: For adolescent patients, be aware of confidentiality concerns with explanation of benefits statements sent to parents 2

Special Considerations

• Adolescent Medicine Specialists: May face challenges as they are often not recognized by insurers as both primary care providers and specialists, which can complicate referrals and reimbursement 2
• After-Hours Care: Consider that some guidelines recommend higher reimbursement rates for services provided during non-traditional hours to increase access to care 2

YCANTH represents a significant advancement in the treatment of molluscum contagiosum, with demonstrated efficacy in clinical trials 3. Understanding the insurance coverage landscape and reimbursement processes will help ensure patients can access this treatment while practices receive appropriate compensation.