Rebate Program - Q2 2022

PROGRAM DURATION: April 1-June 30, 2022

MINIMUM QUALIFYING PURCHASE REQUIRED FOR TIERED REBATE PAYMENT

TIER INSERTS PURCHASED REBATES PER INSERT*
1 1 $30
2 125 $40
3 250 $50
4 500+ $70

* Insert = 1 DEXTENZA intracanalicular insert.

TERMS

  • All purchasing Ambulatory Surgical Centers, Hospital Outpatient Departments, and other healthcare provider entities are eligible to participate in the DEXTENZA Rebate Program.
  • Rebates under this program are not available to multisite customers eligible for rebates under contract with Ocular Therapeutix. If you are a multisite customer, please email strategicaccounts@ocutx.com for more information.
  • Customer remittance details and W-9 tax form are required by calendar quarter-end of the initial applicable quarter in which customer is participating. Remittance form and W-9 tax form may be submitted to: oculrebates@ocutx.com.
  • Rebate payments are only available on qualified purchases based on the invoice date for shipments made to the customer from their authorized servicing distributor or directly from Ocular Therapeutix between April 1 to June 30, 2022. Payments will be made within 60 days after calendar quarter end.
  • This rebate program is not related to any other rebate program for DEXTENZA.
  • Rebates under the program are not available to customers receiving any discounts or rebates for DEXTENZA through any other source.
  • Inserts purchased under 340B program are excluded.
  • Rebates made available under the DEXTENZA Rebate Program represent discounts that must be properly and accurately accounted for, disclosed and reported by purchasers on cost reports or claims for reimbursement to federal healthcare programs (including Medicare and Medicaid) and other third party payor programs requiring such disclosure, and to federal and state agencies upon request, in accordance with all applicable laws and regulations.

PURCHASE OPTIONS

Contact one of our authorized distributors listed below to order DEXTENZA and receive it by the next business day.

Distributor Phone Fax Website
Besse Medical 1-800-543-2111 1-800-543-8695 www.besse.com
Cardinal Specialty
Pharma Distribution
1-855-855-0708 1-614-553-6301 www.cardinalhealth.com/specialtyonline
FFF Enterprises 1-800-843-7477 1-800-418-4333 www.fffenterprises.com
Metro Medical 1-800-768-2002 1-615-256-4194 www.metromedicalorder.com
McKesson
Medical-Surgical
1-855-571-2100 1-800-311-3408 mms.mckesson.com
McKesson Plasma &
Biologics for Hospitals
1-877-625-2566 1-888-752-7626 connect.mckesson.com
McKesson
Specialty Health
1-855-477-9800 1-800-800-5673 mscs.mckesson.com

DISTRIBUTORS

Besse Medical

Phone: 1-800-543-2111

Fax: 1-800-543-8695

Website: www.besse.com

Cardinal Speciality Pharma Distribution

Phone: 1-855-5855-0708

Fax: 1-614-553-6301

Website: inhealth.com/specialityonline

FFF Enterprises

Phone: 1-800-843-7477

Fax: 1-800-418-4333

Website: www.fffenterprises.com

McKesson Medical-Surgical

Phone: 1-855-571-2100

Fax: 1-800-311-3408

Website: mms.mckensson.com

McKesson Plasma & Biologics for Hospitals

Phone: 1-877-625-2566

Fax: 1-888-752-7626

Website: connect.mckensson.com

McKesson Speciality Health

Phone: 1-855-477-9800

Fax: 1-800-800-5673

Website: mscs.mckensson.com

Ocular Therapeutix does not recommend the use of any particular distributor.

Product Active Ingredient Size NDC #
DEXTENZA
(dexamethasone ophthalmic insert) 0.4
(dexamethasone USP) 1's 70382-0204-01
DEXTENZA
(dexamethasone ophthalmic insert) 0.4
(dexamethasone USP) 10's 70382-0204-10
PRODUCTS

DEXTENZA (dexamethasone opthalmic insert) 0.4mg

Active Ingredient (dexamethasone USP)

Size 1’s

NDC # 70382-0204-01

DEXTENZA (dexamethasone opthalmic insert) 0.4mg

Active Ingredient (dexamethasone USP)

Size 10’s

NDC # 70382-0204-10

For billing, certain payers may require the 10-digit NDC to be converted to 11 digits.

For further purchase inquiries, please contact your distributor or Ocular Therapeutix, Inc.

Customer Service: 1-888-315-7906
Monday – Friday 9:00AM - 6:00PM EST/EDT

Billing and Coding

Product Reimbursement

PRODUCT CODE

J1096

J-Code||

Description

Dexamethasone, lacrimal opthalmic insert, 0.1 mg||

Product Code Description

J1096

J-Code||

Dexamethasone, lacrimal ophthalmic insert, 0.1mg1

DEXTENZA has been pass-through status and separate payment with J1096 under the Outpatient Prospective Payment System (OPPS) that governs reimbursement to Hospital Outpatient Department (HOPD) and Ambulatory Surgery Center (ASC).

Procedure Reimbursement

PROCEDURE CODE

68841

CPT|| code

Description

Insertion of drug-eluting implant (including punctual dilation and implant removal when performed into lacrimal canaliculus, each)

Procedure Code Description

68841

CPT§ code

Insertion of drug-eluting implant (including punctal dilation and implant
removal when performed into lacrimal canaliculus, each)

ICD||-10 Codes Associated with Allergic Conjunctivitis

Allergic Conjunctivitis General Right Eye Left Eye Bilateral Unspecified Eye
Acute atopic conjunctivitis H101 H1011 H1012 H1013 H1010
Unspecified acute conjunctivitis H103 H1031 H1032 H1033 H1030
Chronic conjunctivitis H104 H10401 H10402 H10403 H10409
Chronic giant papillary conjunctivitis H1041 H10411 H10412 H10413 H10419
Vernal conjunctivitis H1044

An ICD-10 code, when billing for ocular itching associated with allergic conjunctivitis, will be required.

Other chronic allergic conjunctivitis H1045
Other conjunctivitis H1089
Unspecified conjunctivitis H109
Conjunctivitis H10
Unspecified chronic conjunctivitis H1040

This may not be a complete list of codes. Visit https://www.cms.gov/medicare/coding/medhcpcsgenifo for a complete list of ICD-10 codes associated with Allergic Conjuctivitis.

Customers are responsible for determining the appropriate coding and submission of accurate claims.

How is a pass-through product coded and billed?

  • A unique J-code (J1096) allows ASCs and HOPDs to bill Medicare and other payers for DEXTENZA.
  • The payment is in addition to facility fees that may be paid to ASCs or HOPDs for cataract surgery

No effect on physician fees

  • Payment to surgeons for cataract surgery under Medicare’s Physician Fee Schedule will not be affected by the pass-through payment status of DEXTENZA

No effect on the healthcare system

  • Pass-through regulation is budget-neutral to the healthcare system
  • If surgeons and/or facilities do not access pass-through payments, the allotted funds will be used by other specialties and any remaining amounts will be lost

DEXTENZA360™ provides comprehensive support for obtaining benefits verification and determining the appropriate codes preferred by the payer.

Coverage and reimbursement may vary by payer, contractual agreements, and site of service. Customers are responsible for determining the appropriate coding and submission of accurate claims. Ocular Therapeutix does not guarantee reimbursement or payment of claims.

Work with your DEXTENZA Field Reimbursement Manager to determine billable status for your payers and identify which plans allow for separate payment of drugs, new technologies, and pass-through drugs.

A permanent code used to report non-orally administered drugs that cannot be self-administered. May be accompanied by a procedure-based CPT code.

When submitting a claim, enter a unit of 4 for the DEXTENZA HCPCS code(J1096). The HCPCS descriptor for DEXTENZA is 0.1mg.

||CPT® is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT®), an alphanumeric coding system maintained by the American Medical Association to identify medical services and procedures provided by physicians and other healthcare professionals.

§International Classifications of Diseases (ICD).

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IMPORTANT SAFETY INFORMATION

CONTRAINDICATIONS

DEXTENZA is contraindicated in patients with active corneal, conjunctival or canalicular infections, including epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, varicella; mycobacterial infections; fungal diseases of the eye, and dacryocystitis.

WARNINGS AND PRECAUTIONS

Intraocular Pressure Increase – Prolonged use of corticosteroids may result in glaucoma with damage to the optic nerve, defects in visual acuity and fields of vision. Steroids should be used with caution in the presence of glaucoma. Intraocular pressure should be monitored during treatment.

Bacterial Infections – Corticosteroids may suppress the host response and thus increase the hazard for secondary ocular infections. In acute purulent conditions, steroids may mask infection and enhance existing infection.

Viral Infections – Use of ocular steroids may prolong the course and may exacerbate the severity of many viral infections of the eye (including herpes simplex).

Fungal Infections – Fungus invasion must be considered in any persistent corneal ulceration where a steroid has been used or is in use. Fungal culture should be taken when appropriate.

Delayed Healing – Use of steroids after cataract surgery may delay healing and increase the incidence of bleb formation.

Other Potential Corticosteroid Complications – The initial prescription and renewal of medication order of DEXTENZA should be made by a physician only after examination of the patient with the aid of magnification, such as slit lamp biomicroscopy, and, where appropriate, fluorescein staining. If signs and symptoms fail to improve after 2 days, the patient should be re-evaluated.

ADVERSE REACTIONS

Ocular Inflammation and Pain Following Ophthalmic Surgery
The most common ocular adverse reactions that occurred in patients treated with DEXTENZA were: anterior chamber inflammation including iritis and iridocyclitis (10%), intraocular pressure increased (6%), visual acuity reduced (2%), cystoid macular edema (1%), corneal edema (1%), eye pain (1%), and conjunctival hyperemia (1%). The most common non-ocular adverse reaction was headache (1%).

Itching Associated with Allergic Conjunctivitis
The most common ocular adverse reactions that occurred in patients treated with DEXTENZA were: intraocular pressure increased (3%), lacrimation increased (1%), eye discharge (1%), and visual acuity reduced (1%). The most common non-ocular adverse reaction was headache (1%).

INDICATIONS

DEXTENZA is a corticosteroid indicated for:

  • The treatment of ocular inflammation and pain following ophthalmic surgery.
  • The treatment of ocular itching associated with allergic conjunctivitis.