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So annoyed with my insurance

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Ulcerative Colitis
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Red_34
Forum Moderator
Joined : Apr 2004
Posts : 23581
Posted 7/5/2017 9:38 PM (GMT -7)
I started Remicade little over 5 years ago. I used to have it done at the hospital with no insurance issues. But than switched to a cancer infusion center because I moved and it was closer. Even tho it's an infusion center it's still attached to the hospital and once again no insurance issues. I than received a letter from the insurance company that I now have to have it done at an ambulatory infusion center, at a doctor's office or at home. Due to cost issues.

I had my Remicade today and talked to the coordinator and she said that most insurances are doing this now and if it's a medical necessity they will allow infusions done in hospitals but the GI doc has to appeal it.

I called my GI's office today and they are going to set me up at an ambulatory infusion center. But here's my problem....when I moved and requested a center closer to me, my GI was adamant about me being infused with a full staff hospital unit. I had a bad reaction after my 3rd infusion and now require pre-meds of Benedryl and Solumedrol not to mention that body was chaotic and I needed close monitoring due to my past BP spikes, breathlessness and chest pain.

I haven't had an issue in 2 years tho - so my question is...should I just see how I do at the ambulatory infusion center or demand my GI appeal? I don't know what to do.
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Serenity Now
Veteran Member
Joined : Jan 2009
Posts : 2398
Posted 7/6/2017 6:28 AM (GMT -7)
You prefer the hospital right? Why not have the GI appeal since he (she?) is adamant about you being at the hospital unit. Or do you think it will too much of a hassle? Otherwise I think let them do the appeal and if worst comes to worst you go to the ambulatory center.
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iPoop
Forum Moderator
Joined : Aug 2012
Posts : 16177
Posted 7/6/2017 6:37 AM (GMT -7)
How long do you have until your next infusion is due? I'd start the appeal and maybe it might go through in time. If you end up going to the ambulatory infusion center then just give the monitoring nurse the heads up about possible reactions and make sure they can have the benadryl and Solumedrol ready for you there. Always good to research both sides and see what ends up working for ya.
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ks1905
Veteran Member
Joined : Sep 2005
Posts : 5857
Posted 7/6/2017 6:58 AM (GMT -7)
I would have liked to have my infusions at home or work. Would have saved me a half a day instead of being at a hospital full of germs and sick people.

I found the infusion center to be very sad. Family members with their loved ones who were getting chemo.

Now that you are premedicated then your risks are lower. You could ask for a slower infusion, that will lessen your risks for a reaction even further.

Appeals are usually denied at first, then your GI has to appeal the denial and then provide more information. It's just part of the insurance process, this could take upwards of 3 weeks so I'd start the process as soon as possible.
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Poppie
Veteran Member
Joined : Feb 2014
Posts : 2159
Posted 7/6/2017 8:25 AM (GMT -7)
Incredibly I had to read your post three times before I got it...that's what Prednisone does to you!!

Honestly, in your case, even though you have been fine for a couple of years I would opt for the hospital. Allergies are unpredictable and wouldn't you feel more relaxed knowing that your in the best place if something should occur.

Can you say what happened on your third infusion? I do worry about the same happening to me.

Are you a redhead with really white skin? ....cos often with that kind of colouring we are prone to allergies.
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straydog
Forum Moderator
Joined : Feb 2003
Posts : 18244
Posted 7/6/2017 9:15 AM (GMT -7)
Sherry, when I first started Remicade I reacted the very same way you did & was given the same pre-meds. Like you I never had another problem with infusions. Depending on how frequent you get your infusions would dictate my decision to appeal. I would not want to have a delay getting my infusions because of things being on appeal. You may want to consider the ambulatory center once to see how you do. IF you have any problems, then it should be easier to switch you back over.

Dealing with insurance issues is never easy. Take care.
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FlowersGal
Veteran Member
Joined : Feb 2017
Posts : 880
Posted 7/6/2017 7:16 PM (GMT -7)
Make sure there will not be a greater cost to you with a non hospital setting. I don't know how your insurance works but my medical and prescription are separate. In a hospital setting my entyvio is covered under the medical side but if it was in the drs office the cost of the medication would be covered under the prescription side with a much higher cost to me. Something to check into! Remember ins is looking out for their costs, not your welfare or pocketbook
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Red_34
Forum Moderator
Joined : Apr 2004
Posts : 23581
Posted 7/7/2017 8:31 PM (GMT -7)
All very good points and advice...thank you!

Luckily I have good insurance. They cover almost everything 100%. I have $25 co-pay office visits, $13 brand name prescription coverage ($6 generic) and no pay for my Remicade. I can't complain really I just hate that they keep changing things on me. That they have to make me scramble to get things done.

I'm leaning more towards to warning the nurses at the ambulatory infusion center about my past issues and if something arises than make my GI appeal. I mean after all it has been 2 years since my last reaction.

Poppie, after my 3rd - I had no pre-med. My hands swelled up like balloons and were extremely painful. I had to go to the emergency room and all they could do for me was give me prednisone and pain killers. Every joint in my body hurt. And no, I'm not a natural redhead. In fact I'm Native American lol
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