Prometheus Labs test = $2,500

You meant 250, right?

Thanks! That makes so much more sense to me :) That 1200 number was throwing me.. I didnt know if they were running the test twice or what!

Id pay the 250 out of pocket and ask if they would bill the insurance company anyway so it counted toward any deductibles I had. That's what several specialty labs have done for me.

No, no surgery yet PathogenKiller. I'll back up a bit for clarity. I saw blood and had increased urgency at week 7. I have remicade given to me every 8 weeks at 5mg per kg. GI said we need to run a test to check the level of remicade in your system a few days before the next infusion to check and see if A.) Remicade levels are to low and I should be moved to 7 week intervals of remicade or B.) whether they need to up me from 5mg a kilogram to 10 mg a kilogram of remicade.

I found this on Anthem's website regarding this test, Current Effective Date: 04/15/2014: http://www.anthem.com/medicalpolicies/policies/mp_pw_c164428.htm

Key paragraph: "Investigational and Not Medically Necessary:
The measurement of serum concentrations of tumor necrosis factor antagonist drugs or antibodies to tumor necrosis factor antagonist drugs is considered investigational and not medically necessary under all circumstances."

I paid $250 twice. I did NOT need to provide any tax forms. They did 3rd level appeals, then billed me $250 for each test.

The insurance company says the test is experimental, and they'll ask for studies to support it.

Post Edited (Tornado6) : 5/6/2014 5:38:33 AM (GMT-6)

Holy SHEET! I read the original non edited post to mean you could pay 250 out of pocket up front and just be done with it.

So, if I made more then 57k a year and my insurance only paid 1500 Id owe 1000 with no possible assistance. Yet my doctor needs the test to make good decisions about a pretty serious drug.

That is nutty crazy. Ive never done biologics so I had no idea the money involved in them.

No wonder they say diet doesnt matter in IBD. Patients are cash cows. I thought the money I paid out of pocket on herbs was ridiculous, but with my income Id pay 2500 for that test. That would pay for a year of my herbal protocol.. and I didnt need the intensive protocol near that long.

So, how much does your insurance cover for remicade.. how much do people pay per injection?

Post Edited (PathogenKiller) : 5/5/2014 11:25:01 PM (GMT-6)

I have the EOB for my 4/8 infusion in my hand.

Amount billed - $12,094
Plan discounts - $5,592.85
Plan paid - $6,215.32

I have met my deductible and out if pocket max for 2014, so I only owe $285.83. I'll submit that to RemiStart Extended Care, and they'll probably cover most of it, leaving me with $50 to $90 to pay.


I mistyped earlier. The test is 'investigational' not 'experimental'. The insurance companies don't believe there is enough scientific evidence supporting the test. I think there may not be enough evidence to support the $2,500 price tag. They know they've got a monopoly on the test, so they charge whatever they want. I don't have any other blood work that costs that much.

I had the test in June or July 2013, and Prometheus and BCBS are still going back and forth on coverage. It was one more piece of information that helped me decide to discontinue Remicade. As far as I'm concerned, it save BCBS many thousands of dollars every six weeks.

From everything I've read and been told, my ultimate cost should be $250 if BCBS denies the claim. Even though Prometheus has income limits on its patient-assisstance program ($75K/year, I think), it should still be $250.

So, Tornado, even though you have already paid the deductible you still end up 50-90 out of pocket every 8 weeks?

FYI, my GI's office will reduce the cost of a procedure by approx. 50% if I pay the day of the visit, bypassing our insurance completely.

Ask if they will reduce the cost of what would be billed to your insurance company if you pay the day of the visit.

For example, my colonoscopies are no longer covered by insurance, haven't been since they found a malignant polyp/tumor in 1999, my billing code is different now and the amount applies towards my deductible, $2500.00. Haven't needed a doctor this year (yet) so I was quoted approx. $720.00 for a Colonsocopy, when if I allowed my doctor to bill my insurance and it was rejected, I'd be paying roughly $1500.00 if I went this route.

Some offices refer to this as self-pay.

Also, my GI doctor's billing dept said if they found a concern and it looked like there'd be more tests down the road and I'd be facing more large medical bills, they'd go ahead and bill the insurance, assuming I'd meet that deductible fairly soon. So that was nice, got the impression I could pay as I walked out, woozy and all, but they'd allow me to pay at that point, by then doctor would know if there was a concern she said (for example I knew the exact moment my GI doctor saw my malignant tumor in 1999, the entire room was hushed and eerily quiet, banter went from weather/sports to dead silence, this was during a Flex-Sig obviously). So I'd have to hopefully be alert enough to comprehend after a colonoscopy there wasn't a concern. Haven't had a polyp in 15 years either, food travels thru me rapidly. They say the malignant tumor I got was a fluke, but of course it happened because that's why I became a member here - my life has been utter hell ever since, lol - I go as much as a newborn baby sometimes.

But back to paying the day of, I find that is the way to go if you know you'll save half of the cost.

Hi Everyone, here's some info about Prometheus test that might be useful.

Before getting this test done at Prometheus, I called my Insurance BCBS and explained why I have to go to a out of network lab for this test. They said because none of the in network labs are performing this test, they will be able to cover the cost of the test($2,500) at a In network level. So you can try this out as well.

Another thing I figured out very recently is that Lab corp is performing a test called "Infliximab Concentration and Anti-Infliximab Antibody" which is similar to Prometheus Anser IFX test. Ask your doctor if you can get this done at Lab corp so that it will be 100% covered!

Good luck! Let us know the outcome. I am checking with my GI too.