1 reimbursement GUIDE. Everything You Need to know About reimbursement For omidria . About omidria . omidria is the first and only FDA-approved drug that provides continuous intracameral delivery of NSAID and mydriatic/. anti-miotic therapy during cataract surgery1. omidria contains a non-steroidal anti-inflammatory drug, ketorolac, to prevent miosis and to reduce postoperative pain and an a1-adrenergic receptor agonist, phenylephrine, to maintain ocular pupil diameter O. MIDRIA is easy to integrate into operating procedures: Added preoperatively to irrigation solution1. No other preparation required omidria is supplied as a concentrate in a clear, glass, single-patient-use vial containing 4-mL of sterile solution1.
2 omidria is reimbursed per vial, not per mL. Therefore, providers should use one vial as the billing unit INDICATIONS AND USAGE. omidria is added to ophthalmic irrigation solution used during cataract surgery or intraocular lens replacement and is indicated for maintaining pupil size by preventing intraoperative miosis and reducing postoperative ocular pain. IMPORTANT SAFETY INFORMATION. omidria (phenylephrine and ketorolac injection) 1% / must be added to irrigation solution prior to intraocular use. omidria is contraindicated in patients with a known hypersensitivity to any of its ingredients. Systemic exposure of phenylephrine may cause elevations in blood pressure.
3 Use omidria with caution in individuals who have previously exhibited sensitivities to acetylsalicylic acid, phenylacetic acid derivatives, and other non-steroidal anti-inflammatory 2 drugs (NSAIDs), or have a past medical history of asthma. About This Guide This guide provides information on pass-through, omidria . coding, omidria reimbursement , and more This guide is designed to facilitate timely reimbursement by standardizing claim submissions and ensuring appropriate reimbursement through proper billing and product coding*. Coverage and payment may vary by payer, contractual agreements, and site of service omidria has a unique billing code C9447.
4 Injection, phenylephrine and ketorolac, 4 ml vial Important reminders The omidria ssure comprehensive reimbursement program provides assistance for . financially eligible uninsured or government-insured patients and those with insufficient commercial insurance*. Questions related to a patient's benefits or eligibility for cataract surgery or omidria . should be addressed by calling the omidria ssure Live Assistance Information Hotline at 1-877- omidria (1-877-664-3742), contacting your Omeros representative, or working directly with your payer provider representative Consult your facility-specific payer contracts to determine whether omidria is paid separately from the packaged payment for cataract surgery IMPORTANT SAFETY INFORMATION.
5 The most commonly reported adverse reactions at 2-24% are eye irritation, posterior capsule opacification, increased intraocular pressure, and anterior chamber inflammation. Use of omidria in children has not been established. Please see the Full Prescribing Information for omidria . You are encouraged to report Suspected Adverse Reactions to the FDA. Visit medwatch, or call 1-800-FDA-1088. * Information contained in this guide is provided as a reference for obtaining appropriate and accurate reimbursement for the use of omidria in eligible patients. Omeros does not guarantee reimbursement . omidria ssure program services are subject to change without notice.
6 Please see the Full Prescribing Information for omidria . About Medicare Billing and reimbursement Pass through status for omidria allows ASCs and HOPDs to bill Medicare and other payers for omidria using a Healthcare Common Procedure Coding System (HCPCS). code unique to omidria C9447 Injection, phenylephrine and ketorolac, 4 ml vial. The payment is over and above the facility fees paid to ASCs or to HOPDs for cataract surgery. CY 2017 HCPCS and APC codes for OMIDRIA2. CY 2017 HCPCS CY 2017 long descriptor CY 2017 APC. C9447 Injection, phenylephrine and ketorolac, 4 ml vial 1663. Medicare Part B. Pass-through status allows reimbursement for omidria separate from the packaged Ambulatory Payment Classification (APC) reimbursement for the surgical procedure For pass-through drugs, Centers for Medicare & Medicaid Services (CMS) sets the payment rate at Average Selling Price (ASP) plus 6%.
7 C. heck the CMS website for current quarterly payment rates in the Hospital OPPS. (Addendum B) or ASC Payments (Addendum BB) section Payment rates are updated quarterly by CMS and, during the government sequester, 6% is reduced to There is no patient co-payment for omidria in the HOPD setting. In the ASC setting, the patient may be subject to a 20% co-payment Approximately 90% of Medicare Part B patients have some form of supplemental/. secondary insurance that covers co-payments3, . For government-insured patients with an uncovered out-of-pocket expense and who meet certain financial criteria, Omeros has established the Equal Access Patient Assistance Program as part of omidria ssure , which allows patients to receive omidria at no cost; a free vial is sent to your facility prior to surgery.
8 *Status Indicator Based on currently available information and subject to change without notice. Individual plan coverage, policies, and procedures may vary and should be confirmed. Omeros does not guarantee coverage or payment. o be eligible for the Equal Access Patient Assistance Program, patients must be enrolled prior to surgery. For any T.. patient eligible for the Equal Access Patient Assistance Program, (1) the facility receives a free vial of omidria . prior to surgery and (2) the patient's insurance carrier(s) should not be billed for omidria . omidria ssure program services are subject to change without notice. 4. EQUAL ACCESS . PATIENT ASSISTANCE PROGRAM*.
9 Assistance for financially eligible uninsured or government-insured patients Eligible patients* will receive omidria at no cost Free vial will be sent to your facility prior to surgery Application for free vial must be submitted 5 days prior to date of surgery Please visit for more details and to start enrolling patients today For personalized help, call the omidria ssure Live Assistance Information Hotline at . 1-877- omidria (1-877-664-3742) 9 am 6 pm ET, Monday Friday * To be eligible for the Equal Access Patient Assistance Program, patients must be enrolled prior to surgery. For any patient eligible for the Equal Access Patient Assistance Program, (1) the facility receives a free vial of omidria prior to surgery and (2) the patient's insurance carrier(s) should not be billed for omidria .
10 omidria ssure program services are subject to change without notice. Medicare Part C (Medicare Advantage). Like traditional Medicare Part B, Medicare Advantage plans will cover omidria , but the payment rate may differ from traditional Part B or be subject to payer-specific facility contractual limitations For a Medicare Advantage patient, the specific Medicare Advantage payer should be contacted in advance to determine the level of reimbursement for omidria . Please see the Full Prescribing Information for omidria . About Commercial Insurance Billing and reimbursement WE PAY THE DIFFERENCE . COMMERCIALLY INSURED PATIENT reimbursement PROGRAM. Assistance for patients with insufficient commercial insurance Omeros will pay your facility, on behalf of your patient, the difference between your facility's acquisition cost for omidria and the amount covered by your patient's insurance*.