Medical Benefit and Pharmaceutical Benefit
Since ure-Na is a Medical Food, not a Pharmaceutical, ure-Na is usually covered under the medical benefit of health insurance not the pharmaceutical or drug benefit. .
The best first step to determine coverage options is to contact your insurance company and inform them that a physician has recommended ure-Na, which is a Medical Food. Often insurance companies cover Medical Foods under a DME or Durable Medical Equipment benefit. Insurance companies also cover Medical Foods under a benefit for Enteral Nutritional Therapy.
ure-Na usually requires Prior Authorization (PA) to gain coverage. The prior authorization on the medical side of insurance will require an HCPCS code. The Codes S-9432 is typically used.
The section below reviews coverage options for the following insurance types:
Medicare Advantage, PPO & HMO
Medicaid
Medicare And Medicare Part D
Commercial
VA
Tricare
Indian Health Service
Prior Authorization or Reimbursement for already purchased ure-NA
For plans that may cover ure-Na that are mentioned below, coverage can be Prior Authorized or Pre-Determined by calling the plan and either requesting coverage via the phone or via a pre-determination form. The manner is which plans prefer the authorization to be done (phone or paper) varies by plan so phone contact to get plan guidance is typically the best first step.
For reimbursement for already purchased ure-Na, most plans have a form titled 'Reimbursement for medical services'. This form need to be completed and signed by the Health Care Provider and submitted with copies of receipts.
ClickHEREfor examples of the different forms used for reimbursement and pre-authorization.
Please note that the number one issue we see with reimbursement is when the insurance company is contacted, the agent at the insurance company send the form for Prescription Benefit Prior Authorization.
Medicare Advantage, PPO & HMO
Many Medicare Advantage, Medicare PPO and Medicare HMO plans offer expanded coverage in 2020 for Medical Foods like ure-Na. Coverage is often given under a DME or Durable Medical Equipment benefit , but also may be covered under your Supplemental Benefit or Primary Health Related Supplemental Benefit.
You will have to contact your medicare plan and ask how to request coverage under the Medical Benefit of your Medicare plan, not the Pharmaceutical or Drug Benefit.
To gain coverage for ure-Na, it has to be recommended by a qualified Health Care Provider and has to be considered Medically Necessary.
If you reach out to your insurance provider and speak with an agent and they state that ure-Na is not covered, ask them how to request coverage and a medical review of your request for coverage.
Insurance Carriers have a process to review and authorize coverage for products like ure-Na.
VA Benefit
Ure-Na is on the VA National Formulary (VANF) listed as: UREA,PWDR, ORAL
It is found on line 1784 of the National Formulary list updated June 2024
If you are currently receiving pharmacy benefit from the VA, ure-Na is available as the above listed item.
If you qualify for VA benefit, but you are not currently receiving benefit, please contact your local VA for more information on how to receive VA medical and outpatient pharmacy benefit.
Medicaid
Ure-Na may be covered under your State Medicaid plan. Medicaid may offer coverage under your medical benefit not your prescription benefit. When ure-Na is covered under your medical benefit it may be covered as a DME or Durable Medical Equipment item or it may be covered as Medically Necessary Enteral Nutritional Therapy.
Please contact your State Medicaid plan for coverage options. To be qualified for coverage, ure-Na has to be recommended by a qualified Health Care Provider.
Commercial Insurance
Commercial Insurance is coverage from your employer or from the ACA (Obama Care). Since ure-Na is a medical food not a pharmaceutical, coverage may be obtained under the medical benefit of your heath insurance not the pharmaceutical benefit. Ure- Na may be covered as one of the following items depending on ones insurance: Enteral Nutritional Therapy, or as a Medical Foods or as Medically Necessary Enteral Nutritional Therapy.
For coverage, ure-Na has to be recommended by a qualified Health Care Provider and be considered Medically Necessary.
You will need to reach out to your insurance and ask about coverage options of OTCs & Medical Foods as most plans are different.
Medicare and Medicare Part D
Government issued medicare that is not a Medicare Advantage, PPO or HMO plan does not offer coverage for ure-NA unless it is being administrated by tube feeding.
Coverage for ure-Na under Part D prescription benefit is often denied stating that the Medicare Part D Act does not allow coverage of OTC products. This is partially true in that the Act is for coverage of prescription drug products and it specifically denies coverage for OTC products under the the prescription drug benefit.
More information can be found on this subject at the Medicare (CMS) website by clicking here.
Tricare
Since ure-Na is a Medical Food, Tricare may offer coverage under your Medical Benefit for Nutritional Therapy for Medically Necessary Food. Click HERE to access the Tricare website reviewing coverage options.
To request coverage for ure-Na under your Medical Benefit as Medically Necessary Food, it is our understanding from working with Tricare that form 2642 needs to be submitted.
For more information about coverage for ure-Na, you can contact your Tricare regional contractor. You can find the telephone number for your regional contractor HERE
Indian Health Service
Indian Health Service typically follows the VA National Formulary (VANF). Ure-Na is available under the VANF as UREA15GM/PKT/PWDR,ORAL. Please have the IHS pharmacist reach out to us with any questions.
For help with reimbursement, please call
1-844-980-9933 and leave a message to be contacted by a reimbursement specialist.
