Re: Zostavax for 60-64 yo (or even 50-64yo) -- success getting paid?

[Guest guest]

Have not gotten approval by any insurance. Many patients have contacted their reps. All are being told they can pay for it up front and they may or may not be reimbursed. A local pharmacist explained to me that Medicare has made contracts with the pharmacies via Medicare D but will not cover it given in the doctor's office. So far two local pharmacies are having 3x a year Zostovax clinics and apparently are having no problem getting paid. I suspect the private insurances will follow Medicare's precedent. To: Kim Scheuer ; Anne Goyette ; DeWayne Niebur ; Borchers ; "Bruce Bowen, MD" ; Locke ; Locke ; Practice Management Issues ; practiceimprovement1 < > Sent: Monday, April 23, 2012 3:02 PM Subject: Zostavax for 60-64 yo (or even 50-64yo) -- success getting paid?

We are thinking of diving into the Zostavax shots for those 60-64 using private insurance.Anyone having luck (or problems) getting paid to give this vaccine?Any problem insurances (yes, I know, all of them), but any that are refusing to pay outright?

Of note, this site says Anthem may be covering Zostavax for 50 and up.http://mbcustomercare.blogspot.com/2011/04/anthem-changes-zosatavax-coverage.html

Cigna claims they cover it...although you have to be cautious about those without Preventive Benefit coverage - they won't get it covered.http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/pharmacy/ph_6020_coveragepositioncriteria_zoster_vaccine_live_zostavax.pdf

Coverage Policy Note: Vaccines are covered under most CIGNA medical plans which include a Preventive Benefit. Please refer to the applicable benefit plan document to determine benefit availability and the terms and conditions of coverage. If coverage is available for vaccines, then: CIGNA covers one dose of zoster vaccine live (Zostavax®) as medically necessary for individuals 60 years of age and older for the prevention of herpes zoster (shingles) including those who have had a previous episode of shingles or as currently recommended by the Centers for Disease Control and

Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP). ========================Anybody used the following to get their patients covered?

http://www.rebate4zostavax.com/pro-abouttherebate.shtml

orhttp://www.merck.com/merckhelps/vaccines/more_info.html

===========================One of the problems is the initial cost per dose...MerckVaccines.comMerck & Co., Inc. ZOSTAVAX

(Zoster Vaccine Live)00006-4963-00 4963 Package containing 1 single-dose 0.65-mL vial with diluent$167.15 †---------------------------------------Merck & Co., Inc. ZOSTAVAX

(Zoster Vaccine Live)00006-4963-41 4963 Package containing 10 single-dose 0.65-mL vials with diluent$1,593.18 †============================Besse.com...

Item #

Description

Unit

Form

Unit Price

Quantity

Alerts

28146

ZOSTAVAX SDV 0.65ML W/DILUENT - $20 FEE FOR ORDERS OF 3 OR LESS

MERCK & CO. INC.

NDC: 00006-4963-00

60 DAY TERMS - DROPSHIP, 3-5 BUSINESS DAY DELIVERY - CLICK ON DESCRIPTION FOR DETAILS

Dropship

Each

PDS

173.84

Favorite

28145

ZOSTAVAX SDV 0.65ML W/DILUENT 10/PK

MERCK & CO. INC.

NDC: 00006-4963-41

60 DAY TERMS - DROPSHIP, 3-5 BUSINESS DAY DELIVERY - CLICK ON DESCRIPTION FOR DETAILS

Dropship

Pack

PDS

1,656.91

[Guest guest]

From what I heard, for 60- 65 yo, Primary care office is their medical home. 65+ yo, pharmacy is their medical home.

 WenSan Mateo, CA

Wen, That is great, sounds like a slogan for a sign.Sharon

, Thanks for posting the info about the rebate, I was not aware of that program.

SharonSharon McCoy MDRenaissance Family Medicine

10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax:  www.SharonMD.com

[Guest guest]

Yes, there we go. Finally something is working well!Wen

 

From what I heard, for 60- 65 yo, Primary care office is their medical home. 65+ yo, pharmacy is their medical home.

 WenSan Mateo, CA

Wen, That is great, sounds like a slogan for a sign.Sharon

, Thanks for posting the info about the rebate, I was not aware of that program.

SharonSharon McCoy MDRenaissance Family Medicine

10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax: 

www.SharonMD.com

[Guest guest]

Over 65yo and pharmacies are the medical home!!!

Unbelievable.

I have actually stopped almost all immunizations in my office.

I only have influenza, pneumonia and tetanus.

I have a cash practice plus Traditional Medicare and it is just not worth the

outlay for the vaccines, and hoping someone will pay me for it.

Steve Horvitz

stown, NJ

Founder of the Institute for Medical Wellness

>

> > **

> >

> >

> > From what I heard, for 60- 65 yo, Primary care office is their medical

> > home. 65+ yo, pharmacy is their medical home.

> >

> > Wen

> > San Mateo, CA

> >

> >

> > Wen,

> > That is great, sounds like a slogan for a sign.

> > Sharon

> >

> > ,

> > Thanks for posting the info about the rebate, I was not aware of that

> > program.

> > Sharon

> >

> > Sharon McCoy MD

> > Renaissance Family Medicine

> > 10 McClintock Court; Irvine, CA 92617

> > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax:

> > www.SharonMD.com

> >

> >>

> >>

> >>

> >>

> >>

> >

>

[Guest guest]

1.medicare and have part D plan? then  zostavax is pharmacy benefit they go there and get it and you administer2. Medicare and NO part D  plan? then  you order it tell them  they will pay for it and they do Or can they  get it and pay at pharmacy and bring it to you

3 any other insurance  , patient  calls up first to find out  about coverage and lets you know.I mean look it is better than PAkistan where you bring your IV bottle and tubing and penicillin to the  hospital where they administer it.

oh sorry  am I being  blunt again?Jean

 

Over 65yo and pharmacies are the medical home!!!

Unbelievable.

I have actually stopped almost all immunizations in my office.

I only have influenza, pneumonia and tetanus.

I have a cash practice plus Traditional Medicare and it is just not worth the outlay for the vaccines, and hoping someone will pay me for it.

Steve Horvitz

stown, NJ

Founder of the Institute for Medical Wellness

>

> > **

> >

> >

> > From what I heard, for 60- 65 yo, Primary care office is their medical

> > home. 65+ yo, pharmacy is their medical home.

> >

> > Wen

> > San Mateo, CA

> >

> >

> > Wen,

> > That is great, sounds like a slogan for a sign.

> > Sharon

> >

> > ,

> > Thanks for posting the info about the rebate, I was not aware of that

> > program.

> > Sharon

> >

> > Sharon McCoy MD

> > Renaissance Family Medicine

> > 10 McClintock Court; Irvine, CA 92617

> > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax:

> > www.SharonMD.com

> >

> >>

> >>

> >>

> >>

> >>

> >

>

--      MD          ph    fax

[Guest guest]

Have you had success doing this with the shingles vaccine? I have tried, but pharmacies balk because it is a frozen vaccine and must be used immediately.I'm with Steve. However I no longer administer ANY vaccines in my office.Not worth the cost and hassle for any of them when I can just write a prescription to take to the pharmacy. I keep a copy of my vaccine prescription for chart documentation.Plus I like having my fridge

for lunch and drinks instead of vaccines!Growing up, my ophthalmologist dad kept a bottle of tetanus vaccine in fridge at home right above the bag of pig eyes he got from the slaughter yard. He would practice the latest cataract techniques at the kitchen table after work....("ew, dad! That's gross"). I guess the federal inspectors didn't care how we stored out own personal vaccines!Rhonda Carlson, M.D.Chico, CAIMP inspired low overhead practice since 10/2010To: Sent: Tue, April 24, 2012 11:04:39 AMSubject: Re: Re: Zostavax for 60-64 yo (or even 50-64yo) -- success getting paid?

1.medicare and have part D plan? then zostavax is pharmacy benefit they go there and get it and you administer2. Medicare and NO part D plan? then you order it tell them they will pay for it and they do Or can they get it and pay at pharmacy and bring it to you

3 any other insurance , patient calls up first to find out about coverage and lets you know.I mean look it is better than PAkistan where you bring your IV bottle and tubing and penicillin to the hospital where they administer it.

oh sorry am I being blunt again?Jean

Over 65yo and pharmacies are the medical home!!!

Unbelievable.

I have actually stopped almost all immunizations in my office.

I only have influenza, pneumonia and tetanus.

I have a cash practice plus Traditional Medicare and it is just not worth the outlay for the vaccines, and hoping someone will pay me for it.

Steve Horvitz

stown, NJ

Founder of the Institute for Medical Wellness

>

> > **

> >

> >

> > From what I heard, for 60- 65 yo, Primary care office is their medical

> > home. 65+ yo, pharmacy is their medical home.

> >

> > Wen

> > San Mateo, CA

> >

> >

> > Wen,

> > That is great, sounds like a slogan for a sign.

> > Sharon

> >

> > ,

> > Thanks for posting the info about the rebate, I was not aware of that

> > program.

> > Sharon

> >

> > Sharon McCoy MD

> > Renaissance Family Medicine

> > 10 McClintock Court; Irvine, CA 92617

> > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax:

> > www.SharonMD.com

> >

> >>

> >>

> >>

> >>

> >>

> >

>

-- MD ph fax

[Guest guest]

We just had a patient order the shingles vaccine from his mail order to ship to our office, where we administered.  Not a problem.  I think we sent an rx to the pharmacy and then called them with shipping details so that it wouldn't arrive on a day we aren't in.  Once it arrived, we called the patient, and he came in.

Pratt

 

Have you had success doing this with the shingles vaccine? 

I have tried, but pharmacies balk because it is a frozen vaccine and must be used immediately.I'm with Steve. However I no longer administer ANY vaccines in my office.

Not worth the cost and hassle for any of them when I can just write a prescription to take to the pharmacy. I keep a copy of my vaccine prescription for chart documentation.

Plus I like having my fridge

for lunch and drinks instead of vaccines!Growing up, my ophthalmologist dad kept a bottle of tetanus vaccine in fridge at home right above the bag of pig eyes he got from the slaughter yard.  He would practice the latest cataract techniques at the kitchen table after work....( " ew, dad!  That's gross " ).  I guess the federal inspectors didn't care how we stored out own personal vaccines!

Rhonda Carlson, M.D.Chico, CAIMP inspired low overhead practice since 10/2010

To: Sent: Tue, April 24, 2012 11:04:39 AM

Subject: Re: Re: Zostavax for 60-64 yo (or even 50-64yo) -- success getting paid?

 

1.medicare and have part D plan? then  zostavax is pharmacy benefit they go there and get it and you administer2. Medicare and NO part D  plan? then  you order it tell them  they will pay for it and they do Or can they  get it and pay at pharmacy and bring it to you

3 any other insurance  , patient  calls up first to find out  about coverage and lets you know.I mean look it is better than PAkistan where you bring your IV bottle and tubing and penicillin to the  hospital where they administer it.

oh sorry  am I being  blunt again?Jean

 

Over 65yo and pharmacies are the medical home!!!

Unbelievable.

I have actually stopped almost all immunizations in my office.

I only have influenza, pneumonia and tetanus.

I have a cash practice plus Traditional Medicare and it is just not worth the outlay for the vaccines, and hoping someone will pay me for it.

Steve Horvitz

stown, NJ

Founder of the Institute for Medical Wellness

>

> > **

> >

> >

> > From what I heard, for 60- 65 yo, Primary care office is their medical

> > home. 65+ yo, pharmacy is their medical home.

> >

> > Wen

> > San Mateo, CA

> >

> >

> > Wen,

> > That is great, sounds like a slogan for a sign.

> > Sharon

> >

> > ,

> > Thanks for posting the info about the rebate, I was not aware of that

> > program.

> > Sharon

> >

> > Sharon McCoy MD

> > Renaissance Family Medicine

> > 10 McClintock Court; Irvine, CA 92617

> > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax:

> > www.SharonMD.com

> >

> >>

> >>

> >>

> >>

> >>

> >

>

--      MD          ph    fax

[Guest guest]

Why go to all this work when the patient can purchase and receive at the local pharmacy?DannielleConnected by DROID on Verizon Wireless Re: Re: Zostavax for 60-64 yo (or even 50-64yo) -- success getting paid? 1.medicare and have part D plan? then  zostavax is pharmacy benefit they go there and get it and you administer2. Medicare and NO part D  plan? then  you order it tell them  they will pay for it and they do Or can they  get it and pay at pharmacy and bring it to you3 any other insurance  , patient  calls up first to find out  about coverage and lets you know.I mean look it is better than PAkistan where you bring your IV bottle and tubing and penicillin to the  hospital where they administer it.oh sorry  am I being  blunt again?Jean Over 65yo and pharmacies are the medical home!!!Unbelievable.I have actually stopped almost all immunizations in my office.I only have influenza, pneumonia and tetanus.I have a cash practice plus Traditional Medicare and it is just not worth the outlay for the vaccines, and hoping someone will pay me for it.Steve Horvitzstown, NJFounder of the Institute for Medical Wellness> > > **> >> >> > From what I heard, for 60- 65 yo, Primary care office is their medical> > home. 65+ yo, pharmacy is their medical home.> >> > Wen> > San Mateo, CA> >> >> > Wen,> > That is great, sounds like a slogan for a sign.> > Sharon> >> > ,> > Thanks for posting the info about the rebate, I was not aware of that> > program.> > Sharon> >> > Sharon McCoy MD> > Renaissance Family Medicine> > 10 McClintock Court; Irvine, CA 92617> > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: > > www.SharonMD.com> >> >>> >>> >>> >>> >> > >>--      MD          ph    fax

[Guest guest]

Some patients are not comfortable having vaccines given at the pharmacy; they prefer to have our office administer it.  We don't see it as any different than providing an rx for any other medication, but we do get reimbursed for the administration, which in this case was about $28.

Pratt

 

Why go to all this work when the patient can purchase and receive at the local pharmacy?DannielleConnected by DROID on Verizon Wireless

Re: Re: Zostavax for 60-64 yo (or even 50-64yo) -- success getting paid?

 

1.medicare and have part D plan? then  zostavax is pharmacy benefit they go there and get it and you administer2. Medicare and NO part D  plan? then  you order it tell them  they will pay for it and they do Or can they  get it and pay at pharmacy and bring it to you

3 any other insurance  , patient  calls up first to find out  about coverage and lets you know.I mean look it is better than PAkistan where you bring your IV bottle and tubing and penicillin to the  hospital where they administer it.

oh sorry  am I being  blunt again?Jean

 

Over 65yo and pharmacies are the medical home!!!

Unbelievable.

I have actually stopped almost all immunizations in my office.

I only have influenza, pneumonia and tetanus.

I have a cash practice plus Traditional Medicare and it is just not worth the outlay for the vaccines, and hoping someone will pay me for it.

Steve Horvitz

stown, NJ

Founder of the Institute for Medical Wellness

>

> > **

> >

> >

> > From what I heard, for 60- 65 yo, Primary care office is their medical

> > home. 65+ yo, pharmacy is their medical home.

> >

> > Wen

> > San Mateo, CA

> >

> >

> > Wen,

> > That is great, sounds like a slogan for a sign.

> > Sharon

> >

> > ,

> > Thanks for posting the info about the rebate, I was not aware of that

> > program.

> > Sharon

> >

> > Sharon McCoy MD

> > Renaissance Family Medicine

> > 10 McClintock Court; Irvine, CA 92617

> > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax:

> > www.SharonMD.com

> >

> >>

> >>

> >>

> >>

> >>

> >

>

--      MD          ph    fax

[Guest guest]

yes pharmacies do it HAVe done this many times.  I used to tell patietns to pick it up come fright over/had to be frozen etc but the pharmacy that d oes this  a  big grocery store chain, actually  now hands the patient  a tiny sort of dunking donuts donut hole box with a  ice pack in it and they bring it to me The new rules are it can defrost for 30min anyway.

 

Have you had success doing this with the shingles vaccine? 

I have tried, but pharmacies balk because it is a frozen vaccine and must be used immediately.I'm with Steve. However I no longer administer ANY vaccines in my office.

Not worth the cost and hassle for any of them when I can just write a prescription to take to the pharmacy. I keep a copy of my vaccine prescription for chart documentation.

Plus I like having my fridge

for lunch and drinks instead of vaccines!Growing up, my ophthalmologist dad kept a bottle of tetanus vaccine in fridge at home right above the bag of pig eyes he got from the slaughter yard.  He would practice the latest cataract techniques at the kitchen table after work....( " ew, dad!  That's gross " ).  I guess the federal inspectors didn't care how we stored out own personal vaccines!

Rhonda Carlson, M.D.Chico, CAIMP inspired low overhead practice since 10/2010

To: Sent: Tue, April 24, 2012 11:04:39 AM

Subject: Re: Re: Zostavax for 60-64 yo (or even 50-64yo) -- success getting paid?

 

1.medicare and have part D plan? then  zostavax is pharmacy benefit they go there and get it and you administer2. Medicare and NO part D  plan? then  you order it tell them  they will pay for it and they do Or can they  get it and pay at pharmacy and bring it to you

3 any other insurance  , patient  calls up first to find out  about coverage and lets you know.I mean look it is better than PAkistan where you bring your IV bottle and tubing and penicillin to the  hospital where they administer it.

oh sorry  am I being  blunt again?Jean

 

Over 65yo and pharmacies are the medical home!!!

Unbelievable.

I have actually stopped almost all immunizations in my office.

I only have influenza, pneumonia and tetanus.

I have a cash practice plus Traditional Medicare and it is just not worth the outlay for the vaccines, and hoping someone will pay me for it.

Steve Horvitz

stown, NJ

Founder of the Institute for Medical Wellness

>

> > **

> >

> >

> > From what I heard, for 60- 65 yo, Primary care office is their medical

> > home. 65+ yo, pharmacy is their medical home.

> >

> > Wen

> > San Mateo, CA

> >

> >

> > Wen,

> > That is great, sounds like a slogan for a sign.

> > Sharon

> >

> > ,

> > Thanks for posting the info about the rebate, I was not aware of that

> > program.

> > Sharon

> >

> > Sharon McCoy MD

> > Renaissance Family Medicine

> > 10 McClintock Court; Irvine, CA 92617

> > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax:

> > www.SharonMD.com

> >

> >>

> >>

> >>

> >>

> >>

> >

>

--      MD          ph    fax

--      MD          ph    fax

[Guest guest]

Whether pharmacies do this without balking may depend on where you are. A

couple of years ago, the New York State Dept of Health put out a statement

strongly advising against the practice of patients picking up vaccines from

pharmacies and taking them to their doctors for administration. Because of

that, I try to watch for the OCCASIONAL times that OCCASIONAL pharmacies around

here have a Zostavax clinic, then notify the patients that I know are

interested. What a pain for all of us, and a great way to guarantee low

vaccination rates. I tell my patients that if Medicare really " cared " about

them having the vaccine, it would paid for through Part B, like Pneumovax and

flu.---Sharlene

> >> >

> >> > > **

> >> > >

> >> > >

> >> > > From what I heard, for 60- 65 yo, Primary care office is their medical

> >> > > home. 65+ yo, pharmacy is their medical home.

> >> > >

> >> > > Wen

> >> > > San Mateo, CA

> >> > >

> >> > >

> >> > > Wen,

> >> > > That is great, sounds like a slogan for a sign.

> >> > > Sharon

> >> > >

> >> > > ,

> >> > > Thanks for posting the info about the rebate, I was not aware of that

> >> > > program.

> >> > > Sharon

> >> > >

> >> > > Sharon McCoy MD

> >> > > Renaissance Family Medicine

> >> > > 10 McClintock Court; Irvine, CA 92617

> >> > > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax:

> >>

> >> > > www.SharonMD.com

> >> > >

> >> > >>

> >> > >>

> >> > >>

> >> > >>

> >> > >>

> >> > >

> >> >

> >>

> >>

> >

> >

> > --

> >

> >

> >

> > MD

> >

> >

> > ph fax

> >

> >

> >

> >

>

>

>

> --

>

>

>

> MD

>

>

> ph fax

>

>

[Guest guest]

well of course yep. Everything varies.The disparities are great  Only one pharmacy chain here does this.Legislators have no clue when they mandate somethign like part D or B  as to what it actually means

 The medical marijuana law is new in Maine  On the one hand  patients  need to have a form they are told  to get from a doc. The medical  association says no speciic  form i s  needed The state says  no ,you must use theirs The website is obscure    The law says it has to be on security  paper The state says  it must be on 8 1/2 x 11 security paper- who has that?? You ask the state  and you get a n 18 yr old clerk  who says doctors offices all have that.

 ALice in Wonderland was more organized.speak up and  speak out is the only thing you can do.Write and speak and call, If we do not then we cannot complain.Hey  if i was in Oregon  or Ri I would be making a good living.

 I only share in case someone else can make  use of it. HAppy Wednesday I am off and cleaning out t he strawberry beds You can take out a lot of health care anger on the weeds ,man. 

 

Whether pharmacies do this without balking may depend on where you are. A couple of years ago, the New York State Dept of Health put out a statement strongly advising against the practice of patients picking up vaccines from pharmacies and taking them to their doctors for administration. Because of that, I try to watch for the OCCASIONAL times that OCCASIONAL pharmacies around here have a Zostavax clinic, then notify the patients that I know are interested. What a pain for all of us, and a great way to guarantee low vaccination rates. I tell my patients that if Medicare really " cared " about them having the vaccine, it would paid for through Part B, like Pneumovax and flu.---Sharlene

> >> >

> >> > > **

> >> > >

> >> > >

> >> > > From what I heard, for 60- 65 yo, Primary care office is their medical

> >> > > home. 65+ yo, pharmacy is their medical home.

> >> > >

> >> > > Wen

> >> > > San Mateo, CA

> >> > >

> >> > >

> >> > > Wen,

> >> > > That is great, sounds like a slogan for a sign.

> >> > > Sharon

> >> > >

> >> > > ,

> >> > > Thanks for posting the info about the rebate, I was not aware of that

> >> > > program.

> >> > > Sharon

> >> > >

> >> > > Sharon McCoy MD

> >> > > Renaissance Family Medicine

> >> > > 10 McClintock Court; Irvine, CA 92617

> >> > > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax:

> >>

> >> > > www.SharonMD.com

> >> > >

> >> > >>

> >> > >>

> >> > >>

> >> > >>

> >> > >>

> >> > >

> >> >

> >>

> >>

> >

> >

> > --

> >

> >

> >

> > MD

> >

> >

> > ph fax

> >

> >

> >

> >

>

>

>

> --

>

>

>

> MD

>

>

> ph fax

>

>

--      MD          ph    fax

[Guest guest]

Based on comments...1. If patient has Medicare - you won't get paid through the office for it - I've known this, so just wanted to give to the 60-64 year olds that have private insurance.

2. It is indicated down to 50 years old -- so might be an option for them - on a case by case basis with insurance.3. If I can break even and get a little for the Admin - I would like to pursue giving. The problem I've had with getting through the pharmacy is that the pharmacy often doesn't give us a notice that they got it done, patient often doesn't go, etc.

If I give it in the office, I might make a little money for the effort and also can document the vaccination right away.Agree with Number Needed to Treat issues and Cost of the vaccine concerns.

Anyway, we've ordered up 5 of the doses and will give them to patients with private insurance and see how we do.4. Of note - some patients have a version of insurance that doesn't include preventive care. We've run into cases where someone has Cigna and it's covered - but then the next Cigna patient it isn't covered, because they don't have preventive coverage.

Thanks for everyone's feedback. Locke, MD

[Guest guest]

We have done it very slowly. One insurance at a time.

First Medicare - Patients had to order thru Pharmacy. Charge patients to administer vaccine.

Second, our largest HMO is paying so we offer and make sure patient is aware of their ultimate responsibility. Reimbursement is reasonable so have been offering it.

Third, added two of the larger national insurers after they announced they are reimbursing. However we make patient come in for a separate visit. Margin is too slim to just add it to a routine visit or check up. Not ideal for patients but we have to survive.

Hope this helps. Contact off list if you wish.

Mike