XEOMIN® (incobotulinumtoxinA) Patient Savings Program

FREQUENTLY ASKED QUESTIONS

FREQUENTLY ASKED QUESTIONS

To download a copy of the New Program FAQs, please click here.

What are the Program eligibility requirements?

  • To be eligible, patients must:
    • Be a clinically appropriate patient for therapeutic treatment with XEOMIN, as
      determined by their doctor
    • Be prescribed XEOMIN
    • Be at least 18 years of age
    • Have commercial insurance that covers XEOMIN medication costs
    • Not be enrolled in a state or federally funded prescription insurance program.
      This includes patients enrolled in Medicare, Medicare Advantage, Medicare Part D,
      Part B, Medicaid, Medigap, TRICARE, Veterans Affairs (VA), the Department of
      Defense (DOD) or other federally funded or state funded healthcare programs, as
      well as patients who are Medicare eligible and enrolled in an employer-sponsored
      group waiver health plan or government subsidized prescription drug benefit
      program for retirees. If a patient is enrolled in a state or federally funded
      prescription insurance program, they are not eligible even if they elect to be
      processed as an uninsured (cash-paying) patient
  • Note that Merz reserves the right to change Program Terms and Conditions, including the
    eligibility requirements, at any time.
  • For additional information regarding Program Terms and Conditions, please visit the
    XEOMIN.com website at http://www.xeomin.com/consumers/patient-resources/
    patient-savings-program/

What treatment costs are eligible for reimbursement under the XEOMIN® Patient Savings Program?

  • The new Program is designed to support eligible patients with their actual out-of-pocket XEOMIN medication costs and related administration fees, up to a maximum reimbursement amount of $3,500 per rolling 12 month period.
    • The following costs associated with XEOMIN treatment are eligible for reimbursement to eligible patients, up to the above limit:

      • Any eligible costs specifically associated with a patient’s deductible
      • Any co-pay specifically associated with eligible costs
      • Any co-insurance costs specifically associated with eligible costs
    • The following costs are not eligible and will not be reimbursed:

      • Office visit co-pays not directly associated with XEOMIN treatment
      • Facility co-pays not directly associated with XEOMIN treatment
      • Any other costs excluded by the Program guidelines not specifically
        mentioned above, which are subject to change

Is there a limit on the amount of reimbursement I can request per injection?

  • There is not a “per-injection” reimbursement limit under the XEOMIN® Patient Savings
    Program. Instead, the new Program has a reimbursement limit of $3,500 over a rolling
    12-month period. For example, if your out-of-pocket expenses for your XEOMIN
    medication costs and associated administration fees are $2,000, you can apply the full
    amount to your treatment and still have $1,500 left for your remaining treatments over
    the 12-month period.

What date does the new program go into effect?

  • Enrollment Start Date: Patients may begin enrolling in this Program anytime after May 30, 2016
  • Program Start Date: The new offer is effective for eligible dates of service on or after July 1, 2016

How do I enroll in the Program?

  • Complete a Program Enrollment Application, sign and date it, and mail or fax it to the location listed below. We’ll take care of the rest!

    • The XEOMIN® Patient Savings Program
      PO Box 7017
      Bedminster, NJ 07921
      Fax # 1-844-711-6236
  • You can download an application from XEOMIN.com by visiting: http://xeomin.com/wp-content/uploads/xeomin-savings-application.pdf

The enrollment application has two places for me to sign. Do I have to sign in both places for my enrollment to be processed?

  • No. The first signature line is required for you to participate in the Program, but the second signature line is not required.
  • First Signature Line (Required): Your signature and the date must be included in the blue
    box, under “Section 3: Signatures”.
  • Second Signature Line (Optional): The default reimbursement method under the new
    Program is a check sent directly to you, the patient. If, for your convenience, you would
    prefer for your Program reimbursements to be sent directly to your physician so that he
    or she can apply them towards your outstanding XEOMIN account balance, you can also
    sign and date under the section entitled “Option to Assign Reimbursement for your
    Eligible Costs”. If you later wish to receive payment directly, you can choose to do so by
    completing and submitting a new application.

On the application form, I see a section entitled “Option to Assign Reimbursement for your Eligible Costs”. What does this mean?

  • The default reimbursement method under the XEOMIN® Patient Savings Program is a check mailed directly to your home address.
  • If, for your convenience, you would prefer to have the check mailed to your physician’s
    office so they can apply your Program reimbursement directly to your XEOMIN account
    balance, you can sign under the section entitled “Option to Assign Reimbursement for
    your Eligible Costs”. You are not required to sign this section. Your application will be
    processed regardless of whether or not you sign this section. If you later wish to
    receive payment directly, you can choose to do so by completing a new application.

If I have a XEOMIN injection scheduled between now and June 30, 2016, am I eligible for the new offer?

  • No. XEOMIN injections received on or after July 1, 2016 are eligible for the new
    Program/offer. If you are enrolled in the current XEOMIN® Copay Program and receive
    an injection on or before June 30, 2016, you can still request reimbursement support
    under the current Program, which offers reimbursement assistance of up to $500 per
    injection for eligible expenses.

What documents do I need to submit in order to participate in the XEOMIN® Patient Savings Program?

  • To determine if you are eligible for the Program, you must first complete and sign a
    XEOMIN® Patient Savings Program Enrollment Application. You can download an
    application here.
  • Once you are enrolled in the program, you must submit an Explanation of Benefits and/or
    Specialty Pharmacy receipt within 120 days from the date of service to determine the
    amount of benefits you may be eligible to receive.

    • Explanation of Benefits (EOB) – After you’ve visited a doctor, clinic, or hospital, you
      and your provider will receive an EOB from your insurance plan. Some of the
      information listed on an EOB includes the portion of the provider’s charges eligible
      for benefits under your insurance plan, the amount the insurance company paid to
      your provider, the amount you’re responsible for, and what portion of your
      deductible you have met

      • Your insurance company may mail a hardcopy of your EOB to your
        home, or they may post it to an online patient portal. If you have
        questions regarding how to obtain your EOB, please call your insurance
        company.
    • Specialty Pharmacy Receipt – If you obtain your XEOMIN from a Specialty
      Pharmacy, please request a receipt from the Specialty Pharmacy for any amounts
      you pay them directly.

What is the time limit for submitting my request for reimbursement?

  • All claims must be submitted for reimbursement within 120 days from the date of
    service listed on your Explanation of Benefits or Specialty Pharmacy receipt.

Am I required to re-enroll in the XEOMIN® Patient Savings Program every year?

  • Yes. You are required to re-enroll and have your eligibility evaluated every 12 months.

What if I have not received my reimbursement check in the mail?

  • Please ensure you are enrolled in the Program AND that either you or your physician has
    submitted an Explanation of Benefits (EOB) and/or Specialty Pharmacy (SP) receipt to the
    Program. If you have completed the above requirements, and it has been more than 15
    business days since you submitted your EOB or SP receipt, please call 1-844-291-7026 to
    speak with a customer service representative.

I assigned my program benefits to my physician. How will I know if my physician received the reimbursement following my claim submission?

  • If your request for reimbursement is successfully processed, your physician will receive
    your funds along with a letter stating that the reimbursement is being sent to them on
    your behalf. The letter will also state that the funds are to be applied towards your
    outstanding XEOMIN account balance. In addition, you will receive a letter confirming
    that a check for the approved amount was processed and sent to your designated
    physician.

I assigned my reimbursement benefits to my provider, but he/she is stating they never received a check from the Program. What should I do?

  • Please ensure you are enrolled in the Program AND that either you or your physician has
    submitted an Explanation of Benefits (EOB) to the Program. If you have completed the
    above requirements, and it has been more than 15 business days since you submitted
    your EOB, please call 1-844-291-7026 to speak with a customer service representative.

I pay cash for my XEOMIN treatment because I do not have insurance. Am I eligible for this program?

  • No. To be eligible for the XEOMIN® Patient Savings Program, a patient must have
    commercial insurance that covers XEOMIN therapy. If you do not have insurance, you
    may be eligible for our XEOMIN® Patient Assistance Program. Please click here for the
    XEOMIN® Patient Assistance Program Enrollment Application.