Reimbursement Issues for Plaquenil Therapy

Plaquenil (hydroxychloroquine sulfate) is used by physicians to treat rheumatoid arthritis and lupus erythematosus when other drugs have failed, although its exact mechanism of action is unknown in both conditions.  It is also gaining credence as treatment for antiphospholipid antibody syndrome (APS).  Originally, it was used to treat malaria.

The drug has a number of possible side effects; some of them affect the eye.  An eye exam is indicated for patients taking Plaquenil because the drug can cause retinal toxicity, and permanent visual field and visual acuity loss.  Early detection has been the goal for eye care providers since some patients may experience continued functional loss and depigmentation even after stopping use.

This FAQ answers the following questions:

  1. What is Plaquenil?
  2. Why do ophthalmologists see patients taking Plaquenil?
  3. Will Medicare and other payers cover eye exams and tests for Plaquenil patients?
  4. What diagnoses are used for the exam and any needed testing?
  5. What sort of testing is usually done for patients taking Plaquenil?
  6. Is OCT testing indicated for Plaquenil patients?  Will payers cover this test?
  7. If a patient has changes due to Plaquenil, how should we bill?
  8. If Plaquenil is planned but not yet started, is the exam covered?

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