Patient coverage types
Patient coverage types
Acquisition
Alternate injection/infusion centers
Billing and coding
Annotated claim forms
Explore your patient's insurance type to determine the right acquisition method
My patient has Medicare coverage
OVERVIEW
LEQVIO is a subcutaneous injection administered by a health care professional.
LEQVIO is available to all of your Medicare Part B Fee-for-Service patients today. Medicare covers 80% of office-administered products under Part B.
If patients have supplemental insurance (Medigap), their supplemental coverage may pick up the additional 20%.
For additional information on
specialty drug coverage and
acquisition methods, click
here.
HELPFUL RESOURCES
Buy-and-Bill Checklist
Download PDFDistribution & Acquisition Flashcard
Download PDFAnnotated Claim Forms
View FormsPROCESS STEPS
PROCESS STEPS
My patient has commercial coverage
OVERVIEW
LEQVIO is a subcutaneous injection administered by a health care professional.
New patients with commercial insurance may be eligible to receive two free doses of LEQVIO if coverage is delayed or denied. Limitations apply.*
Your dedicated Specialist is with you every step of the way to help navigate this initial phase of coverage.
For additional information on
specialty drug coverage and
acquisition methods, click
here.
HELPFUL RESOURCES
Buy-and-Bill Checklist
Download PDFDistribution & Acquisition Flashcard
Download PDFAnnotated Claim Forms
View FormsPROCESS STEPS
PROCESS STEPS
*Eligible patients must have commercial insurance, a valid prescription for LEQVIO, and a prior authorization that has been denied or pending for greater than 3 calendar days. Program provides up to two (2) doses of free medication. Program is not available to patients who are uninsured or whose medications are reimbursed in whole or in part by Medicare, Medicaid, TRICARE, or any other federal or state program, or where prohibited by law. No purchase necessary. Program is not health insurance, nor is participation a guarantee of insurance coverage. Other limitations may apply. Novartis reserves the right to rescind, revoke, or amend the Program and discontinue support at any time without notice.
My patient is government-insured
or uninsured
MEDICAID
Coverage under Medicaid varies by state. Contact your patient's plan to understand specific guidance.
UNINSURED OR UNDERINSURED
If uninsured or underinsured patients express financial hardship, the Service Center can help connect them with the Novartis Patient Assistance Foundation to determine eligibility.
LEQVIO Distributors
If you intend to buy-and-bill, LEQVIO can be ordered through our authorized distributors
Distributor
Contact Information
Website
AmerisourceBergen Besse Medical (physician distribution)
Phone: 1-800-543-2111
Fax: 1-800-543-8695
https://www.besse.com
AmerisourceBergen Oncology Supply (practice distribution)
Phone: 1-800-633-7555
Fax: 1-800-248-8205
https://www.oncologysupply.com
AmerisourceBergen Specialty Distribution (health systems and specialty pharmacy)
Phone: 1-800-746-6273
Fax: 1-800-547-9413
https://www.asdhealthcare.com
Cardinal Health Specialty Pharmaceuticals
Phone: 1-866-677-4844
https://specialtyonline.cardinalhealth.com
CuraScriptSD
Phone: 1-877-599-7748
Fax: 1-800-862-6208
https://curascriptsd.com
Henry Schein
Phone: 1-800-772-4346
Fax: 1-800-329-9109
https://www.henryschein.com
McKesson MPB
Phone: 1-877-625-2566
Fax: 1-888-752-7626
https://connect.mckesson.com
McKesson Specialty
Care Distribution
Phone: 1-855-477-9800
Fax: 1-800-800-5673
https://mscs.mckesson.com
Metro Medical
(A Cardinal Health Company)
Phone: 1-800-768-2002
Fax: 1-615-256-4194
https://metromedicalorder.com
Novartis does not recommend the use of any particular distributor.
Group Purchasing Organizations
If you intend to work with a group purchasing organization (GPO), you can order through the following companies
GPO
Contact Information
Website
Cornerstone Rheumatology GPO
Phone: 1-800-768-2002
https://www.cardinalhealth.com/cornerstonerheumatology
Intalere
Phone: 1-877-711-5600
https://www.intalere.com/contact-us
MosaicGPO Solutions
Phone: 1-800-768-2002
https://www.cardinalhealth.com/mosaicgpo
Onmark GPO
Phone: 1-800-482-6700
https://www.mckesson.com/Specialty/Group-Purchasing/
Premier
Phone: 1-877-777-1552
https://solutioncenter@premierinc.com/contact-us
The Resource Group
Phone: 1-844-753-4778
https://theresourcegroup.com/Participants
VitalSource GPO
Phone: 1-877-453-3972
https://www.cardinalhealth.com/vitalsourcegpo
Vizient
Phone: 1-800-842-5146
https://vizientsupport@vizientinc.com
Novartis does not recommend the use of any particular GPO.
Specialty Pharmacies
Novartis has made LEQVIO widely available through specialty pharmacies (SP), in the event white-bagging is required or preferred.
The following SPs have self-identified as supporting HCP-administered medical benefit products like LEQVIO. This means they currently support white-bagging for physicians and have familiarity and comfort with processing under both the medical and pharmacy benefits. This may be an option for private payers that offer Medicare Advantage and commercial health plans. Medicare Part B does not apply, as it is mandatory buy-and-bill.
This list of SPs is not comprehensive and other SPs may be available to you and your patients. Inclusion in this list is not an endorsement and Novartis cannot guarantee accuracy of this list or coverage of product. Novartis does not recommend or require the use of any particular pharmacy. Any SP in the LEQVIO distribution network that fits these criteria may be added to this list by contacting leqvio.spteam@novartis.com. This list is periodically updated.
Specialty Pharmacy
Contact Information
Website
Albertsons
Phone: 1-877-466-8028
Fax: 1-877-466-8040
Albertsons.com/specialtycare
AllianceRx Walgreens Pharmacy
Phone: 1-855-244-2555
Fax: 1-800-332-9581
alliancerxwp.com
Blue Sky
Phone: 1-866-822-0103
Fax: 1-833-898-3992
blueskyspecialtypharmacy.com
Hill Country Pharmacy
Phone: 1-844-295-5516
Fax: 1-844-295-5518
hillcountrypharmacy.com
Kroger
Phone: 1-866-580-8100
Fax: 1-866-794-4844
krogerspecialtypharmacy.com
Meijer
Phone: 1-855-263-4537
Fax: 1-877-222-5036
meijerspecialtypharmacy.com
Noble Health Services
Phone: 1-888-843-2040
Fax: 1-888-842-3977
noblehealthservices.com
Orsini Specialty Pharmacy
Phone: 1-800-372-6153
Fax: 1-877-515-9670
https://www.orsinispecialtypharmacy.com
Publix
Phone: 1-855-797-8254
Fax: 1-863-413-5723
publix.com/pharmacy/pharmacy-services/specialty
ReCept
Phone: 1-866-326-1425
Fax: 1-866-326-9731
https://www.recept-pharmacy.com
Soleo Health Inc.
Phone: 1-844-575-1515
Fax: 1-877-393-1618
https://www.soleohealth.com/orlando.html
Walmart
Phone: 1-407-826-6984
Fax: 1-866-537-0877
walmart.com/cp/specialty-pharmacy/4101489
Absolute Pharmacy
(Puerto Rico)
Phone: 1-787-892-8700
Fax: 1-787-496-1010
Alivia Specialty Pharmacy
(Puerto Rico)
Phone: 1-787-925-1989
Fax: 1-787-925-1015
http://aliviahealth.com/specialty
Axium Healthcare
(Puerto Rico)
Phone: 1-787-780-7200
Fax: 1-787-779-1430
https://www.axiumpr.com
Special Care Pharmacy Services
(Puerto Rico)
Phone: 1-787-781-4585
Fax: 1-787-783-2951
https://specialcarepr.com
SPS Specialty Pharmacy Services (Puerto Rico)
Phone: 1-787-704-2025
Fax: 1-787-704-2027
https://www.spscaguas.com
Novartis does not recommend the use of any particular SP.
LEQVIO Returns
If you have questions about LEQVIO returns, please contact Novartis Pharmaceuticals Corporation by phone at 1‑800‑526‑0175, or email Novartis.phuseh@novartis.com. For returns of product damaged in shipment, please contact your distributor.
If you intend to refer to an alternate injection/infusion center to administer LEQVIO,
you can find a site that is convenient for your patient with our locator tool
The LEQVIO locator tool allows you to enter
your patient's ZIP Code and find centers
in their local area*
infusion center locator
*The list of injection/infusion centers provided in the locator is not comprehensive, and other injection/infusion centers may be available to you and your patients. These lists are maintained by a third party, and inclusion in the locator is not an endorsement of any of the centers.
Looking to learn more about the alternate injection/infusion center process?
Alternate Injection/InfusionCenter Guide
You can register your practice as an
alternate injection/infusion center
for LEQVIO on
the National Infusion
Center Association website.
Novartis does not recommend the use of any particular alternate injection/infusion center.
Now available: Permanent J-code J1306 effective July 1, 2022 for all sites of care
Understanding the permanent
J-code, J1306
Learn how and where to apply the permanent
J-code, J1306, when submitting a claim for LEQVIO
The information herein is provided for educational purposes only. Novartis cannot guarantee insurance coverage or reimbursement. Coverage and reimbursement may vary significantly by payer, plan, patient, and setting of care. It is the sole responsibility of the health care provider to select the proper codes and ensure the accuracy of all statements used in seeking coverage and reimbursement for an individual patient.
Billing and coding information
Below you will find codes that may be relevant for LEQVIO.
To find a full list of codes that may be related to LEQVIO, download our Billing & Coding Guide. Codes based on site of care are also provided below.
Download the Billing & Coding GuideThe information herein is provided for educational purposes only. Novartis cannot guarantee insurance coverage or reimbursement. Coverage and reimbursement may vary significantly by payer, plan, patient, and setting of care. It is the sole responsibility of the health care provider to select the proper codes and ensure the accuracy of all statements used in seeking coverage and reimbursement for an individual patient.
Coding for physician's office administration
The codes detailed in this section may be used when LEQVIO is administered at a physician's office.
The table below provides common miscellaneous procedure and drug codes related to administration of LEQVIO.
Healthcare Common Procedure Coding System (HCPCS) level II code(s)1
HCPCS is a collection of standardized codes that represent medical procedures, supplies, products, and services. The codes are used to facilitate the processing of health insurance claims by insurers.
HCPCS code
Descriptor
Billing units
HCPCS code
J1306
Descriptor
Injection, inclisiran, 1 mg
Billing units
284
Current Procedural Terminology (CPT) code2
CPT codes, also known as service codes, are a universal system that identifies medical procedures. Each procedure is given its own unique 5-digit code that identifies to health insurance companies what type of care was provided.
CPT code*
Descriptor
96372
Therapeutic, Prophylactic, and Diagnostic Injection (specific substance or drug; subcutaneous or intramuscular)
National Drug Code (NDC)3
The National Drug Code is a unique 10-digit, 3-segment number. It is a universal product identifier for drugs in the United States present on all over-the-counter and prescription medication packages and inserts.
Many NDC numbers listed on drug packaging are in a 10-digit format. The NDC number is essential for proper claim processing when submitting claims for drugs used; however, to be recognized by payers, it must be formatted into an 11-digit 5-4-2 sequence. This requires a zero (0) to be placed in a specific position to meet the 5-4-2 format requirement. As not all NDC numbers are set up the same, the table below demonstrates how to achieve the 11-digit NDC code for LEQVIO.
Please note, because many practice management systems automatically remove the hyphens, be sure they are excluded from submission on the claim.
Tradename
Package strength
10-digit format
NDC number
New format
NDC number for payer
Tradename
LEQVIO
Package strength
284 mg/1.5 mL single-dose prefilled syringe
10-digit format
4-4-2
NDC number
0078-1000-60
New format
5-4-2
NDC number for payer
00078-1000-60
00078-1000-60
International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
ICD-10-CM is a comprehensive list of codes used for identifying and capturing a specific diagnosis.
To find a full list of ICD-10 codes that may be relevant for LEQVIO, download our Billing & Coding Guide.
Download the Billing & Coding Guide*CPT © 2022 American Medical Association. All rights reserved.
References: 1. Centers for Medicare & Medicaid Services. CMS HCPCS Application Summaries and Coding Recommendations: First Quarter, 2022 HCPCS Coding Cycle. Accessed May 2, 2022. https://www.cms.gov/files/document/2022-hcpcs-application-summary-quarter-1-2022-drugs-and-biologicals.pdf 2. Codify by AAPC. CPT® 96372. Accessed May 3, 2022. https://www.aapc.com/codes/cpt-codes/96372 3. LEQVIO [prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corp; 2021.
Coding for hospital outpatient department administration
The codes detailed in this section may be used when LEQVIO is administered at a hospital outpatient department.
The table below provides common miscellaneous procedure and drug codes related to the administration of LEQVIO.
Healthcare Common Procedure Coding System (HCPCS) level II code(s)1
HCPCS is a collection of standardized codes that represent medical procedures, supplies, products, and services. The codes are used to facilitate the processing of health insurance claims by insurers.
HCPCS code
Descriptor
Billing units
HCPCS code
J1306
Descriptor
Injection, inclisiran, 1mg
Billing units
284
Current Procedural Terminology (CPT) code2
CPT codes, also known as service codes, are a universal system that identifies medical procedures. Each procedure is given its own unique 5-digit code that identifies to health insurance companies what type of care was provided.
CPT code*
Descriptor
96372
Therapeutic, Prophylactic, and Diagnostic Injection (specific substance or drug; subcutaneous or intramuscular)
Revenue codes3
Revenue code
Descriptor
0636
Drugs requiring detailed coding
0250
General pharmacy
0500
General outpatient services
0510
General clinic services
National Drug Code (NDC)4
The National Drug Code is a unique 10-digit, 3-segment number. It is a universal product identifier for drugs in the United States present on all over-the-counter and prescription medication packages and inserts.
Many NDC numbers listed on drug packaging are in a 10-digit format. The NDC number is essential for proper claim processing when submitting claims for drugs used; however, to be recognized by payers, it must be formatted into an 11-digit 5-4-2 sequence. This requires a zero (0) to be placed in a specific position to meet the 5-4-2 format requirement. As not all NDC numbers are set up the same, the table below demonstrates how to achieve the 11-digit NDC code for LEQVIO.
Please note, because many practice management systems automatically remove the hyphens, be sure they are excluded from submission on the claim.
Tradename
Package strength
10-digit format
NDC number
New format
NDC number for payer
Tradename
LEQVIO
Package strength
284 mg/1.5 mL single-dose prefilled syringe
10-digit format
4-4-2
NDC number
0078-1000-60
New format
5-4-2
NDC number for payer
00078-1000-60
00078-1000-60
International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
ICD-10-CM is a comprehensive list of codes used for identifying and capturing a specific diagnosis.
To find a full list of ICD-10 codes that may be relevant for LEQVIO, download our Billing & Coding Guide.
Download the Billing & Coding Guide*CPT © 2022 American Medical Association. All rights reserved.
References: 1. Centers for Medicare & Medicaid Services. CMS HCPCS Application Summaries and Coding Recommendations: First Quarter, 2022 HCPCS Coding Cycle. Accessed May 2, 2022. https://www.cms.gov/files/document/2022-hcpcs-application-summary-quarter-1-2022-drugs-and-biologicals.pdf 2. Codify by AAPC. CPT® 96372. Accessed May 3, 2022. https://www.aapc.com/codes/cpt-codes/96372 3. Noridian Healthcare Solutions. Revenue Codes. Accessed May 3, 2022. https://med.noridianmedicare.com/web/jea/topics/claim-submission/revenue-codes 4. LEQVIO [prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corp; 2021.
*CPT © 2022 American Medical Association. All rights reserved.
References: 1. Centers for Medicare & Medicaid Services. CMS HCPCS Application Summaries and Coding Recommendations: First Quarter, 2022 HCPCS Coding Cycle. Accessed May 2, 2022. https://www.cms.gov/files/document/2022-hcpcs-application-summary-quarter-1-2022-drugs-and-biologicals.pdf 2. Codify by AAPC. CPT® 96372. Accessed May 3, 2022. https://www.aapc.com/codes/cpt-codes/96372 3. Noridian Healthcare Solutions. Revenue Codes. Accessed May 3, 2022. https://med.noridianmedicare.com/web/jea/topics/claim-submission/revenue-codes 4. LEQVIO [prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corp; 2021.
The information herein is provided for educational purposes only. Novartis cannot guarantee insurance coverage or reimbursement. Coverage and reimbursement may vary significantly by payer, plan, patient, and setting of care. It is the sole responsibility of the health care provider to select the proper codes and ensure the accuracy of all statements used in seeking coverage and reimbursement for an individual patient.
Completing forms accurately may help with timely reimbursement
Two forms are commonly used to submit claims for payment.
As you prepare your claims, you can use our Claim Filing Checklist as a reference to help to ensure your claims are being submitted with the necessary information.
Download Claim Filing Checklist
Coding for a physician's office |
CMS-1500 form
Coding for a physician's office | CMS-1500 form
The sample claim form provided below is only an example.1 The sample claim form provided below is only an example.1 It is always the provider's responsibility to determine the appropriate health care setting and to submit true and correct claims for the products and services rendered. Providers should contact third-party payers for specific information on their coding, coverage, payment policies, and fee schedules.
-
This Centers for Medicare & Medicaid Services (CMS) CMS-1500 Form is used for billing for prescribed medications administered in HCP offices
-
It should be completed (generally electronically) and submitted to the insurance provider in accordance with your organization's policies
Field
Information required
Box 21A
Primary diagnosis code (ICD-10-CM)
Box 21B
Secondary diagnosis code (ICD-10-CM)
Box 23
Prior authorization number, if available
Box 24A
In the non-shaded area, list the date of service. In the shaded area, give a
detailed drug description. List the N4 indicator first, then the 11-digit NDC number.
Third is the unit of measurement qualifier; the unit quantity is listed at the end.
Example N400078100060ML1.5
Box 24D
Enter the appropriate HCPCS code for J1306 for LEQVIO use as required by the payer.2 Include the appropriate CPT code to report the administration procedure, 96372.3
Box 24E
Enter the diagnosis code reference letter (A or B) as shown in Box 21 to relate the date of service and the procedures performed to the primary diagnosis. If there is more than one diagnosis required for a procedure code, only reference one letter from Box 21.
Box 24G
Include the appropriate number of billing units for LEQVIO: 284 mg=284 billing units
References: 1. Centers for Medicare & Medicaid Services. CMS-1500 Sample Form. Accessed May 3, 2022. https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1500.pdf 2. Centers for Medicare & Medicaid Services. CMS HCPCS Application Summaries and Coding Recommendations: First Quarter, 2022 HCPCS Coding Cycle. Accessed May 2, 2022. https://www.cms.gov/files/document/2022-hcpcs-application-summary-quarter-1-2022-drugs-and-biologicals.pdf 3. Codify by AAPC. CPT® 96372. Accessed May 3, 2022. https://www.aapc.com/codes/cpt-codes/96372
Coding for a hospital outpatient
department | CMS-1450 (UB-04) form
Coding for a hospital outpatient department | CMS-1450 (UB-04) form
The sample claim form provided below is only an example.1 It is always the provider's responsibility to determine the appropriate health care setting and to submit true and correct claims for the products and services rendered. Providers should contact third-party payers for specific information on their coding, coverage, payment policies, and fee schedules.
The sample claim form provided below is only an example.1 It is always the provider's responsibility to determine the appropriate health care setting and to submit true and correct claims for the products and services rendered. Providers should contact third-party payers for specific information on their coding, coverage, payment policies, and fee schedules.
-
The CMS-1450 (UB-04) form is used for billing for prescribed medications administered in hospital outpatient settings
-
It should be completed and submitted (generally electronically) to the insurance provider in accordance with your organization's policies
Field
Information Required
Box 42
Enter the appropriate revenue code corresponding with the HCPCS code in Box 44 (eg, 0636 revenue code for drugs requiring detailed coding, and/or 0250 for general pharmacy). Then enter the appropriate revenue code corresponding with the CPT code in Box 44 (eg, 0500 for general outpatient services or 0510 for general clinic services).2
Box 43
Enter a detailed drug description for the payer. The N4 indicator is listed first,
the 11-digit National Drug Code number is listed second, a code describing the
unit of measurement qualifier is listed third (eg, ML for milliliters), and the
unit quantity is listed at the end.
Example N400078100060ML1.5
Box 44
Enter the appropriate HCPCS code J1306 for LEQVIO use as required by the payer.3 To report the administration procedure, enter an appropriate CPT code, 96372.4
Box 46
Include the appropriate number of billing units for LEQVIO: 284 mg=284 billing units. Some payers may refer to the actual quantity administered via Box 43.
Box 63
Treatment authorization codes
Box 66
Primary diagnosis code (ICD-10-CM)
Secondary diagnosis code (ICD-10-CM)
References: 1. Centers for Medicare & Medicaid Services. CMS-1450 Form. Accessed May 3, 2022. https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-1450 2. Noridian Healthcare Solutions. Revenue Codes. Accessed May 3, 2022. https://med.noridianmedicare.com/web/jea/topics/claim-submission/revenue-codes 3. Centers for Medicare & Medicaid Services. CMS HCPCS Application Summaries and Coding Recommendations: First Quarter, 2022 HCPCS Coding Cycle. Accessed May 2, 2022. https://www.cms.gov/files/document/2022-hcpcs-application-summary-quarter-1-2022-drugs-and-biologicals.pdf 4. Codify by AAPC. CPT® 96372. Accessed May 3, 2022. https://www.aapc.com/codes/cpt-codes/96372
The information herein is provided for educational purposes only. Novartis cannot guarantee insurance coverage or reimbursement. Coverage and reimbursement may vary significantly by payer, plan, patient, and setting of care. It is the sole responsibility of the health care provider to select the proper codes and ensure the accuracy of all statements used in seeking coverage and reimbursement for an individual patient.
