interesting remicade insurance info

hi everyone! Sooo.... my insurance has changed! Which is enough to stress out a "healthy" person, what with all the associated paperwork & phone calls. Since I take a boatload of super expensive meds, it has stressed me out majorly. What I have found though- my previous insurer, Harvard Pilgrim HMO- my remicade infusions were part of my medical benefit- not prescription drug coverage, as the method of administration is in a hospital setting. So, they covered my infusions in full- not one dime did I spend on remicade over the past year & a half. My new insurer, BlueCross Blue Shield HMO- they consider remicade infusions part of the outpatient/day surgery benefit- which means I would be paying $250 per infusion, with a max of $1000 per calendar year. Bummer! Although the total cost of my yearly infusions are well over $10,000... so $1000 should not bum me out. Now here is the interesting insurance part- the hospital that I get my infusions at bills them as chemotherapy/radiology, becaussue they are administered in the same fashion as chemo drugs. Under pretty much any insurer, chemo treatments are covered in full!!!! My BlueCross Blue Shield insurance only has a $1000 deductible for inpatient chemo treatments- not outpatient! SO- it looks like I will once again have my infusions covered in full! YAY!!!! So if anyone on here is having issues with remicade & insurance- check how the administrating party is billing it- maybe they can bill it as chemo, in which case most co-pays will not apply. It's sort of like pulling one over on the insurance companies- I'm all for that. Of course, I'll let you know if I do incur a charge- my next infusion is the end of August, & I have to go thru the hoops to submit prior auth.'s for that & my Imuran. Such a hassle.... I always fear that an insurer will deny the remicade outright.

Yeah, tell me about that love/hate thing! I have this fear that my insurance "folder" or whatever has a giant red post-it flag on it... "Watch out for this one! She's costing us a mint! Let's drop her ASAP!". I never felt that way 'til I saw Michael Moore's movie, Sicko. See, it's not really how your insurance company allots remicade in your benefits, it's how the facility bills it. That'll be the determing factor as to how much, if any, you will pay. If "my" hospital billed it as outpatient surgery, I'd be liable for $250- since they bill it as chemo, I'm liable for $0. And I know my BCBS HMO most definitely does not consider remicade chemo! Good luck with your new insurance- make sure you get all your referrals & prior auth.s submitted (& approved!) before you get that next infusion.