UHC Navigate (HMO) + Tysabri infusions...

Hey Everyone,

I have just ventured into the land of HMOs with UnitedHealthcare's Navigate plan. I had been on their Choice Plus plans prior to this for a couple years, but now am with an employer that is smaller in size and can't afford the "flexible plan". They do have it as an option, but it is an extra $200 per month and ends up costing me more in the long run over the year than the new UHC Navigate HSA plan I have (which has a $3,500 out of pocket maximum verses $5,000 for the more expensive, easier flexibility plan). The good news is when I hit the $3,500, everything.. including meds... are covered 100%. Not to mention I am on the Tysabri patient assistance program, so they cover a good portion of that $3,500.

I am curious if anyone has had this type of plan before, and what I need to do in order to receive my Tysabri? I have the infusion coming up in a week, and am already getting the ball rolling with my IBD doc/specialty pharmacy pre-auth dept. However, one thing UHC nor the doctors office can answer for me is whether or not I need a referral to get my infusions, since they are prescribed by my specialist and not my primary. They seemingly can attach doctors appointments to the referrals, but it doesn't seem the same for the infusions.

Can anyone help me in this all? It is so confusing, but overall this option was the best one for my disease and covering the Tysabri.

Thank you for your help!

I was on the phone with UHC today, and they said they don't need a referral for anything other than "appointments or procedures that will be billed under the doctor's name". Supposedly, because my infusion is outpatient, this is billed under the hospital and not a specific doctor. My doctors office seems like they FINALLY figured things out now that I actually told them they need to go to the UHC website to fill out the referral, and not just "refer" me as they had done the last 3 times.

I asked her to verify for me that the infusions she saw on my last insurance plan would be covered without referral, and she said correct. I have her name, the date I called, and the time... so hopefully she knows what she is talking about.

I guess I just have been lucky to not have had any HMO's in the 5 years that I have had insurance on my own. Headache central!