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Remicade infusions and insurance coverage-??

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Crohn's Disease
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Posted 9/19/2007 4:10 PM (GMT -7)
My husband was diagnosed with Crohn's in 2002, and was told yesterday that he now needs Remicade.  I am so confused trying to figure out how our insurance company is viewing this, and wanted to hear some of your experiences!  Our insurance policy covers prescription drugs at 100% (and Remicade is on their covered list), but our policy covers infusions at only 80/20.  So, does this mean that it will pay for 100% of the cost of the actual DRUG Remicade because we have 100% prescription drug coverage, or will they lump in the cost of the Remicade with the whole infusion service and therefore only pay 80% of the cost of the Remicade?  What have been your experiences?
Sorry to ramble, we're just worried that we can't afford this!
Posted 9/19/2007 6:03 PM (GMT -7)
my insurance has been very good.I have a nurse/case manager that comes out to my house from my insurance and decides on my next plan of care.She puts all my meds into the computer and it will tell her what tests they want me to do next.They were the ones that told me to get a bone scan due to steroiduse.With my remicade they have it set up to where i do my infusion at the doctors office and all i pay is my 20.00 co-pay and they pay for the other 10 grand.They have been very good with my meds and everything else.I hope this helps.I was dx in oct. of 2006 and have been on remicade since jan of 2007.
Posted 9/19/2007 7:17 PM (GMT -7)
I have UC but wanted to respond because it sounds a lot like my insurance. I pay $18 for the actual drug which Caremark ships to the hospital where my Remicade is administered. Our insurance covers 80 percent of the hospital's costs to administer it and then we pay the other 20 percent. I would doublecheck with your insurance but it sounds like you would only have to pay 20 percent of the costs for the actual infusion site. For me that works out to about $75 per time, (not counting my $18 co-pay for the actual drug). Hope this helps.
Posted 9/19/2007 8:48 PM (GMT -7)
It REALLY depends on how the doc handles it. I've had it through 4 different ways and 2 different insurance policies.

1 - done in office by nurse pract, paid 20% until OOP max was met ($2k) then covered 100%. Medication included in 20%. Each infusion was $400-$500 until I hit the max (that was my 20% portion)

2 - done at hospital in outpatient area by a nurse. Paid 20% until hit OOP max. Drug was ordered through hospital pharmacy. My portion was $800-900 until OOP max was met because hospitals grossly overcharge and that was 20% of each infusion. Greedy people.

3 - done in office by nurse, paid an extended office visit fee plus whatever my mail order pharmacy cost. The med was sent directly to the docs office but I got the bill. The drug was $80 for my copay and the extended office visit was about $80 each time.

4 - done in the hospital while a patient. Drug cost was rolled into hospital bill and I paid a 20% of that total so I don't know what it broke down to. No added charge for the infusion itself since I was already a patient.

Your best bet is to 1) find out how your doc does the infusion and where. Check with that place on what your portion will be. 2) if you will be ordering your med through your mail order pharmacy, contact them for copay info.
Posted 9/20/2007 4:02 AM (GMT -7)
This is really helping, you guys, thank you so much!!  We are very eager to read about as many experiences as possible!!

I will definitely call our doc and see how they obtain the meds; our insurance does utilize a specialty pharmacy (in fact it's Caremark, I believe), so...

Posted 9/20/2007 8:25 AM (GMT -7)
Sounds to me like you would have to pay the 20% which is a lot.  Remicade is not considered a presription drug.  It's under procedures or something.  I had to quit my job becasue I had a PPO that was 60/40 and my part was 40% and they wanted me to pay $5,000.00 per infusion.  Nice copay.  So I quit and got a job that I could go on the HMO right away without having to wait for open enrollment.  So now I get it for $0.00 copay.  AAnd this was done IN THE DOCTOR'S office.  The whole thing was a nightmare with a PPO.  I had to wait 3 months to quit and start a new job and wait the introductory period for new benefits. 
Posted 9/20/2007 12:31 PM (GMT -7)
I go to a place that just does infusions. I originally went to a doctors office and had the remicade mailed to the office for a 20.00 copay and then paid 20% for the office visit. The new place that does just infusions normally lumps it all together and pay 20% but since I had started with the mail order remicade at $20.00 they let me keep it that way and so I pay $20.00 for the drug and usually about $86.00 for the office visit. Works out pretty good.
Posted 9/20/2007 12:52 PM (GMT -7)
Remicade is considered a "chemotherapy" on my health insurance. Since they cover chemotherapy 100%, I don't have to pay anything, not even a co-pay.

Blue Choice.
Posted 9/20/2007 2:09 PM (GMT -7)
My drug provider is Caremark as well, but I had my infusions done at the infusion center in my hospital. I ended up having it completely paid for, something about how if there's no generic for the medication, there's no copay. And, I think it was billed differently than a prescription drug as well.
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