Advances in Microbiome-Based Therapies for Recurrent C difficile Infection - Episode 9

Insurance Coverage of FMTs in CDI

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Experts comment on insurance coverage as a factor for the broader use of FMTs for the management of CDI.

Stuart Johnson, MD: Going back to this issue we talked about before, is insurance coverage going to be a big factor in broader use of this product or any FMT product, if you will. Are you aware of the insurance coverage status of FMT or any other products? Big question, isn't it?

Joseph Reilly, PharmD, BS, BCGP: Well, in my institution when we use this product, we get a prior authorization, and the majority of our patients have Medicare. As Candace has said, this doesn't have to be so difficult. It's a small-volume administration. Nurses give patients enemas in their room; patients self-administer enemas at home. It's 150 cc even if they have to use the bathroom afterwards. There's no re-administration. It's one and done. Patients lay on their side for 15 minutes and then can leave. We get a prior authorization before administration to ensure we get reimbursed.

Stuart Johnson, MD: Have you had experience giving this to patients in this new era where it's FDA approved?

Joseph Reilly, PharmD, BS, BCGP: We have at our institution.

Stuart Johnson, MD: What are the insurance issues?

Joseph Reilly, PharmD, BS, BCGP: My understanding is, you can’t speak for everybody, hospital states are different, but my understanding – Candace can answer this better than I can. The coverage is excellent all across the country and I know Ferring has this information. From speaking to colleagues around the country, the reimbursement is excellent.

Stuart Johnson, MD: Before this was a big deal, the major biobank, if you will, was OpenBiome. Many patient places had their own screening process, did it themselves, but OpenBiome was used by most people in the country for getting the product. It wasn't so expensive that it was an issue until before the pandemic when the prices went up double or threefold. At that point, gastroenterologists, in particular, weren't willing to bite. They'd cover the cost of it as long as they could charge for the administration by an endoscopy itself. The hope is now – that's reassuring to hear that you've administered it to patients in this current era where insurance companies are free to approve it, if you will.

Transcript edited for clarity