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Sterile Sodium Hyaluronate Solution 1.0% Tribute Pharmaceuticals Canada Inc. 544 Egerton St., London, ON, N5W 3Z8 www.tributepharma.com Reimbursement Assistance Information This list is an example of some of the insurance companies who should cover NeoVisc ® . If your insurance company is not on this list, please contact them with the following information. 1. Identify NeoVisc ® first by NAME. Most insurance companies should recognize NeoVisc ® . 2. If NeoVisc ® is not recognized by name: Ask the customer service representative to check under the category “viscosupplementation” or “synovial fluid replacement” - NeoVisc ® belongs to this class of devices. 3. If viscosupplementation and NeoVisc ® are not recognized: Try providing a Pseudo-DIN or PIN provided by the Atlantic Pharmaceutical Services (APSI) 96599991 or 96599999. NeoVisc ® is approved by Health Canada as a medical device and, as such, does not have a Drug Identification Number (DIN), only a Pseudo-DIN or PIN. 4. Should the drug card reject NeoVisc ® , this does NOT mean that the patient is not covered. Patients may be required to fill out an “Insurance Claims” form to apply for reimbursement under the extended health portion of their plan. An accompanying physician letter would enhance reimbursement. 5. If after following guidelines 1-4 and reimbursement is still denied, then the next step is a physician letter addressed to the Human Resources Department (Employee Benefits Manager) of the Employer whose Benefits Plan the patient is covered under. It is recommended that the patient personally deliver this letter to the Human Resources Department – Benefits Plan Manager. The content of the letter should briefly summarize the patient’s medical condition and why NeoVisc ® is necessary for their personal and professional well being. The Employer Benefits Plan Manager can then contact the Insurance Company and direct them to reimburse the patient. Health Canada Medical Device License# 5442 Pseudo-DIN/PIN 96599999 Three (3) doses of 2 mL Commments • Covered under health benefits • Treated as a drug for coverage (e.g. 80%, 90%, 100%) • NeoVisc ® - Viscosupplement injections – Indicate which joint • NeoVisc ® should be recognized by name • Treated as a drug coverage (e.g. 80%, 90%, 100%) • Make reference to: Pseudo-DIN or PIN# 96599991 and #96599999 • Covered under extended health benefits – Viscosupplement Injection • Not a drug or medical device, recognized by class and by name • Special Product • NeoVisc ® should be recognized by name • Mention NeoVisc ® is not a drug • Recognized as a synovial fluid replacement / viscosupplement • Exceptional product status if the criteria are met • NeoVisc ® or Synovial Fluid Replacement • Treated as a drug for coverage (e.g. 80%, 90%, 100%) • Viscosupplement-Injections (not drug) • Note: max 3 injection per limb/lifetime • Viscosupplement – injection (not a drug) • Mention that NeoVisc ® is an INJECTION • Treated as a drug coverage (e.g. 80%, 90%, 100%) • Make reference to: Pseudo-DIN or PIN# 96599991, #96599999 & #00990004 • Patient to submit a request for coverage in writing, include Pseudo-DIN or PIN • Covered under ID# 96599991 and # 96599999 • Patient pays direct and submits claim to be assessed on an exception basis • Recommended submission: physician letter, prescription & invoice for NeoVisc ® 1-866-647-5088 1-800-267-0215 1-800-957-9777 1-888-711-1119 1-877-422-6487 1-800-268-6195 1-800-667-4511 1-800-234-8881 1-800-565-4550 403-296-9400 1-800-465-2581 1-800-361-6212 1-800-665-3365 Company Canadian Forces Health Services Desjardins The Empire Life Insurance Company The Great-West Life Assurance Company Green Shield Canada Industrial Alliance Life Insurance Company Manulife Financial Medavie Blue Cross Ontario Blue Cross SSQ Standard Life – Calgary Standard Life – Ontario Sun Life Financial The Chamber of Commerce Veterans Affairs Canada Workplace Safety and Insurance Board (WSIB) Pseudo-DIN/PIN 96599991 Single does (6 mL) M-MK-25 140102 Please Note: Insurance Companies may cover “viscosupplements” but the patient’s policy may not, even though it is through the same Insurance Company. The Non-Insured Health Benefits (NIHB) Program of the First Nations and Inuit Health Branch (FNIHB)
