Prometheus Blood Test & Insurance

Since going on biologics rather recently, I’ve been having to get my medicine levels periodically measured by a special blood test processed through Prometheus Labs. The cost of the test is not covered whatsoever by my insurance, and the test is not offered through Quest (my in-network lab). Can anyone explain from personal experience what the actual issue is here between the insurance companies and this lab, as I believe other people have had problems with their insurance companies not paying for these tests as well?

Post Edited (FLGuy) : 8/3/2020 6:37:28 PM (GMT-6)

It is unusual to only have one in-network lab. Labcorp is offering a lot of the biologic therapeutic drug monitoring tests now - you might check into that. Additionally, Prometheus has a patient assistance program where I believe they will pay for most of the cost of the test once per year. The co-pay with this program ranges from $75 to $250, depending on your annual household income.

https://www.prometheusbiosciences.com/wp-content/uploads/2020/04/KPADA1405-2019-Links-Patient-Tearsheet-Updatev7.pdf

As far as the actual issue, my understanding is that the concept of therapeutic drug monitoring being of vital importance is a relatively new discovery, and insurance companies have not caught up yet. Sort of like how most insurance companies still won't allow Entyvio or Xeljanz as a first-line treatment even though the research suggests they should be.

I have Quest only for in network labs. After a fight with my doctors office, I got them to use Labcorp. Even though Labcorp is out of network for me, my insurance only allowed 25$, and I prefered to pay that out of pocket than up to $250 with Promethius. Labcorp sends the lab directly to Promethius.