Clarifying the insurance process for Xolair

[Guest guest]

Hello - I hope everyone had a good Memorial Day weekend!

I am preparing to talk to my doctor about trying Xolair for my throat

problems. First I need to do a little more homework though! I would

like to be as knowledgeable as possible before even approaching my

doctor about it. Below I have summarized my understanding about how

insurance coverage usually works for Xolair. Please let me know if

this sounds right!

This is my understanding:

In order to determine which insurance company (medical or

prescription) should provide coverage, I need to know how my doctor's

office administers Xolair.

Scenario 1: If the doctor's office orders and supplies the Xolair

themselves, then my medical insurance will most likely be responsible

for coverage.

Scenario 2: If the doctor prefers to order Xolair through my

specialty pharmacy and have it shipped to them, then my pharmacy

insurance will cover this portion, but the administration of the shot

will be covered by medical.

Two more questions: Since I would be using Xolair off-label, it is

probable that my insurance will deny coverage. In this situation, do

you think it's best for the doctor to explain my medical situation

when first applying for approval, or is it best to submit this during

the appeals process? Also, if I am denied coverage, does anyone know

if I would typically still receive the insurance's discounted pricing

on the Xolair?

Thanks so much for your help!

, 32, Louisville