Access & Reimbursement Support

This information is provided for educational purposes only. Bristol Myers Squibb cannot guarantee insurance coverage or reimbursement. Coverage and reimbursement may vary significantly by payer, plan, patient, and setting of care and may be subject to frequent change. It is the sole responsibility of the healthcare provider to select the proper codes and ensure the accuracy of all statements used in seeking coverage and reimbursement for an individual patient.

Patient Access & Insurance Coverage

Coverage and reimbursement for Bristol Myers Squibb CAR T cell therapies may vary based on payer-specific requirements, potential site/setting of care, and patient-specific benefits.

Benefit verification (BV) with a patient’s payer is critical to help identify specific considerations for each appropriate patient for Bristol Myers Squibb CAR T cell therapies. Our Insurance Coverage Lookup tool can provide information to assist in the BV process, or Cell Therapy 360® can provide BV assistance.

Download the CAR T cell therapy BV checklist for a helpful guide on the type of information that needs to be confirmed during the BV process for CAR T cell therapy treatment.

Key fact

Treatment centers should confirm access prior to apheresis scheduling, including BV, prior authorization (PA) approval, and single case agreement (if required).

For questions, please contact your Bristol Myers Squibb Account Representative or call Cell Therapy 360 at 1-888-805-4555.

Medicare Fee-for-Service (FFS) Patients

Coverage Policy

CAR T cell therapies are covered by Medicare FFS for FDA-approved use(s) per the National Coverage Determination (NCD), according to which, healthcare facilities administering CAR T cell therapy must be certified by the respective manufacturer under the applicable Risk Evaluation and Mitigation Strategy (REMS) program.1

Under the NCD, consistent coverage conditions for CAR T cell therapies apply to all A/B Medicare Administrative Contractor (MAC) jurisdictions.1

NCD flashcard

Patient Benefits

CAR T cell therapy treatment-related out-of-pocket (OOP) costs for Medicare FFS patients may vary based on:

  • Site of care (hospital or clinic) and setting of care (inpatient or outpatient)
  • Secondary or supplemental insurance benefits (eg, employer-sponsored plan, Medigap)

Key fact

For Medicare FFS patients without secondary or supplemental insurance, out-of-pocket costs are typically capped per service in the hospital outpatient setting, at the level of the inpatient deductible (up to $1,484 in 2021).2*

*Full Part B 20% coinsurance applies when outpatient services are provided in an Outpatient Prospective Payment System (OPPS)–exempt hospital or an outpatient clinic/physician office.

Visit the Resource Library for informative downloadable tools.

Medicare Advantage (MA) Patients

Coverage Policy

Although MA plans may issue their own medical policies and PA requirements for FDA-approved CAR T cell therapies, coverage for MA patients must be consistent with the NCD.3,4 Specific PA requirements may vary among MA plans.


Patient Benefits

Patient benefits may vary among MA plans:

  • Out-of-network restrictions and referral requirements
  • Patient cost-sharing across sites/settings of care
    • Coinsurance
    • Copayment
    • Annual deductible
    • Out-of-pocket maximum amounts*

Key fact

For MA patients, OOP costs for Part A and B services are subject to an annual maximum (on average, up to $5,091 for in‑network services in 2021).5†

*Site/setting of care decisions are at the sole discretion of the treating physician.

Federal regulations require MA plans to have a limit on annual patient OOP costs for Part A and B services, which are not to exceed $7,550 (in-network) or $11,300 (in-network and out-of-network) in 2021.5

Visit the Resource Library for informative downloadable tools.

Commercial Patients

Coverage Policy

CAR T cell therapies are generally covered by commercial plans, typically with detailed PA requirements that are consistent with the FDA-approved labeling.6

Specific PA requirements may vary among commercial plans.

Click here for product-specific PA submission tip sheet.


Patient Benefits

Patient benefits may vary among commercial plans:

  • Out-of-network restrictions and referral requirements
  • Patient cost-sharing across sites/settings of care
    • Coinsurance
    • Copayment
    • Annual deductible
    • Out-of-pocket maximum amounts

Key fact

OOP costs for most commercial patients are subject to an annual maximum (on average, up to $4,039 for in-network services in 2020).7

Visit the Resource Library for informative downloadable tools.

CAR T cell therapy resources

CAR T cell therapy BV checklist Template letter of intent Template letter of medical necessity Template letter of appeal NCD flashcard

Product-specific resources

For product-specific resources, click here.

CAR=chimeric antigen receptor.

This information is provided for educational purposes only. Bristol Myers Squibb cannot guarantee insurance coverage or reimbursement. Coverage and reimbursement may vary significantly by payer, plan, patient, and setting of care and may be subject to frequent change. It is the sole responsibility of the healthcare provider to select the proper codes and ensure the accuracy of all statements used in seeking coverage and reimbursement for an individual patient.

References

  1. CMS. Decision memo for chimeric antigen receptor (CAR) T-cell therapy for cancers (CAG-00451N). https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=291. Accessed June 22, 2020
  2. Medicare.gov. Medicare costs at a glance, 2021. https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance. Accessed June 14, 2021.
  3. CMS. Billing instructions for beneficiaries enrolled in Medicare Advantage (MA) plans for services covered by Decision Memo CAG-00451N. MLN Matters SE19024. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19024.pdf. Accessed June 22, 2020.
  4. CMS. Medicare Managed Care Manual, Chapter 4. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf. Accessed June 22, 2020.
  5. Kaiser Family Foundation. Medicare Advantage in 2021: premiums, cost sharing, out-of-pocket limits and supplemental benefits. June 2021. https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2021-premiums-cost-sharing-out-of-pocket-limits-and-supplemental-benefits/#. Accessed July 7, 2021.
  6. Data on file. Bristol-Myers Squibb Company. 2020.
  7. Kaiser Family Foundation. Employer health benefits. 2020 annual survey. http://files.kff.org/attachment/Report-Employer-Health-Benefits-2020-Annual-Survey.pdf. Accessed October 22, 2020.