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Avatar universal

Health insurance coverage..need advice

Spoke to doctors office and asked about coverage..as far as...does everything get covered except for co pay. My doctors office co pay is  15 dollars. I have blue cross/blue sheild.

She said every insurance co is different and I should call them and tell them I will be starting tx and ask if they want me to get meds from pharmacy or mail order and to ask them about coverage. I was assuming insurance was picking up the bill, hope they are. Now I'm panicky.

Do people with insurance have a big out of pocket with this or will it be just my 15 dollar co pay? i will be calling, but would like some feedback or any advice you may have.

also if you can think of any other questions I should ask insurance when I call.

24 Responses
Avatar universal
NOW you call the insurance company. LOL. BTW I waited until the 11th hour myself :)

Only advice is to be quite specific when you call the insurance company. The drugs you want to mention are whatever peg you're taking, ribavirin, and the rescue drugs Procrit and Neupogen.

A bit of caution...the first time I called the insurance company they told me NOTHING was covered :) This is common. In my case, I was talking to the medical department when I should have been talking to the "personal injectible" department or something like that. Insurance companies are often huge bogs of data sifted badly by misinformed personnel. It took me three or four calls until I finally got a supervisor in the right department who had the right information.

In my case, I had the customary co-pay ($10-15) for my doctors visits and all costs for Pegasys, Ribavirin and Procrit were covered except for I think a $15 co-pay each month for the ribavirin. BTW I posted to you in the "Rosacea" thread below.

-- Jim
Avatar universal
Thanks jim.

I was under the impression that the doctor's office called the insurance co. They gave me that impression, maybe its just to see that THEIR visits are paid for...but they should have told me that I needed to call the insurance for meds...i never assumed that.

Thanks though. Don't leave this place again without asking, And the answer is "no." if you do ask. lol
Avatar universal
First off HEY JIM WELCOME BACK we have been looking for you!!!!!

Second - call yourself - it is WORTH the time and energy to make SURE that you can get the proper drugs paid for.  Treatment is said to be like $20,000 but it's REALLY at about $100,000 for some of us with tests and extra meds and stuff.  

If you have any problems the doctors office usually has someone who is an expert and what I had to do was have them work on it with me to get things paid.  It's a bother.

But a lot of insurance companies just DONT wanna give up the money no matter what you do!  so it's best to call, get a name of who you are speaking to and find out if for example they will approve procrit and at what point.....etc.

I have EXCELLENT insurance and had a lot of trouble getting those little $6000 boxes through believe me.

There are a lot of 'outside' costs to treatment also.
1. Dentist - get them choppers done now if you have ANY cavities cause the interferon is gonna eat them up and turn them into mush.
2. Lotions for riba rash
3. Mouthwashes, meds for the sores
4. Special foods - because we can't eat like we used to unfortunately (GOD I want some buffalo chicken wings!!! :(
5. Syringes (if they aren't covered)
6. Bottled water @ like 5 a day costs a LOT a month!
7. Tylenol and painkillers
Etc etc etc etc

Things like that - I could probably list 25 of them in two minutes.  We don't think to add them in because they are not "medications" but they usually turn out being MORE expensive because you have to pay CASH for OTC...and not a copay.
Avatar universal
I have BC/BS also. My co-pay is $30.  My plan is a $1000 ded. $80/60 PPO(individual policy I got off internet)and I'm supposed to be able to go to anyone in my network for the co-pay BUT MY Doctor(in network)is charging me more and billing me. So far I have just been ignoring it but I may have to call my BC/BS case worker and ask for an explanation.

Also The lab procedures are another place they can "get" you. Before I started going to my GI --I was at a medical clinic for the testing and DX. When I had to have labs I was given a lab appt. and just showed up to the lab/xray waiting room and signed in on a clipboard, and the lab tech would come and get me when my name came up. No co-pay.

Well my GI's lab is (same one just set up differently)is within his office and when I go to appt for lab it's the same except the GI's nurse takes me back to lab. Well they are trying to charge me $22 dollars for this little "escort". So I would ask how labs are going to be handled because you are going to certainly have enough of them, for it to be an issue.

I got a good deal on my meds. only $45/month for all interferon and riba.
Avatar universal
Good to see you posting, we missed you!
30678 tn?1217992847
I have blue cross/shield also, had no problems getting meds peg/ribavirin and all the tests, but when I relapsed is when the problems started, they said the FDA standard of tx is 48wks and retreatment was not approved for 72wks by FDA and "experimental" I had to get my meds through pegassist, after showing them the refusal letter from Blue Cross they are sending it for free. So do what your Doc says, and hope you get it right the first time. Wal-Mart called Blue Cross and verified the tx first time and thats who you need to call a week or so in advance of first shot cause the cost they don't keep pegasys on hand.
Avatar universal
thanks for all the info....don't know what I'd do without ya's

Avatar universal
"injectable department", thanks for mentioning that, I'll try that first.

This is work,... with all the money the doctors make, we shouldn't have to do anything but show up for appointments.
100019 tn?1335923317
With my ins co the pills were classified as prescription plan and the Peg-Intron (interferon) was classified as major medical.  Both fell under different parts of the ins plan.  Find out your prescription out of pocket max and your major medical out of pocket max.
96938 tn?1189803458
How'd the x-ray, or whatever it was, turn out?
Avatar universal
So sorry to break thread but just read horrible thread on end stage death (above). OMG OMG, does this happen? The thought of my son being there during this is just too much!!!
96938 tn?1189803458
That's something I never wanted to learn about but have spent the last few minutes researching. Based upon Mary's questions, and some of the replies going back to her, it seems like a subject that you may have to learn more about in support of your kids. Sorry about this Merlino, things are stacking up a bit on you too.  The Janis site has a listing of support groups by state, but I don't know what the support entails.
Avatar universal
I got you beat I only pay $20 for the month (peg/Riba).  ;)

I am just busting your chops here and teasing.  When I add in all of the "other" meds that I have to take cause of this treatment now it comes to roughly $100 a month (co went up to $10 from 7.50) but I take about ten meds or so.  TOO MANY. Then...adding in all of the doctors and tests and blah blah .........(ie: Endocronologist, Shrink for the Paxill, GI, Primary Care, 2nd Opinion @ Dr. J. etc) and it REALLY starts to build up.  And now they raised the insurance from $10 to $25 for "specialists"...they get you COMING and GOING but I thank GOD every day that I have this insurance.  I could NOT come up with the minimum $100,000 to do the treatment without it.

I am so so so so mad that the GI is actually CHARGING you I can't stand it.  If you are ALREADY there to see him...they STILL charge you this?  That sounds 100% WRONG.  Wrong.  Wrong.  It sounds like charging you cause he looks out of his left eye and then sending you a bill for the right one.  I am SO PISSED I am about to lose control.  I have to eat my chocolate candy NOW! It's the only thing that might help.

I HATE that so much. I'm working myself into a FRENZY!


Avatar universal
MyOwn...Your doctor's office will probably have to pre certify a lot of stuff. With so many different insurance companies combined with the assembly line nature of many doctor's offices, this process is often far from smooth with many delays and misunderstandings. Guess who has to be the one to be on top of things?

You also might hear things from your doctor's office like for example the 4-week PCR won't be covered or they won't cover Procrit unless your hgb is below **. Just assume everything they tell you is WRONG because half the time it is:) Again, you have to make your own calls

example -- my original NP told me she would have to "fight" for my four-week PCR (viral load test). Reality -- I switched doctors and they gave me a PCR every week for the first six weeks with no fighting, nothing out of my pocket, just a prescription. Same with the Procrit, I got mine at hgb 11.8 or so.

If the doctor writes the rx and is willing to pre-cert if necessary, most things seem to get through. On the other hand, if your doctor doesn't know the system -- including the diagnosis codes that work -- things may not work as smoothly. That's another reason to see a hepatologist -- or at least a well experienced and agressive GI -- if possible as they have more experience pushing things through and equally important they understand the IMPORTANCE of why they should be pushed through.

In that vein, you haven't already, make sure you discuss both the week 4 PCR as well as early intervention of Procrit, should you start to exhibit signs of anemia regardless of absolute hgb numbers. Better to face this now then when you're feeling faint and gasping for air only for some nurse to tell you that your "NUMBERS" look good :)

Way and NY... Thanks for the nice words, hope you're doing OK.

-- Jim
Avatar universal
Thanks again..

I did discuss the procrit, because of what I learned from all you guys on forum. I would have never known to do so. She would use procrit if necesary, I told her I read that lowering dosage might put my svr at risk. She said she wouldn't lower dosage, but would use rescue drugs.

I didn't think I would have anemia symptoms and still have good hgb numbers. So, I guess you mean the symptoms might show before the numbers drop? This is so overwhelming all the things we have to know about.

The practice I go to has over 2,000 hep cases.This is all they do. This gives me some hope that they know what they are doing, but I still feel more comfy getting info here because of people's personal experience,knowledge and plain old common sense that many on board seem to have.

Plus, the support is so vital at this time. We do smack each other around here now and then, but I think we all have been getting along pretty good lately.

My doc said she will give a weekly pcr. I guess that means for the first few weeks? I had asked when she said that.."insurance will cover?" She said she hasn't had a problem. Now the lexapro thingy.

Did you go on lexapro? I remember you asking someone about it? I really hate to take extra meds. I asked the nurse when I was on the phone if it filters through the liver or kidneys, she wasn't sure, so I guess she will check it out.

Probably most filter through liver, but a liver guy I know (retired) told me that for the rest of my life, always try to get meds that filter through kidneys. That might not always be possible though.

I wish I could fall asleep and have someone wake me up when tx is finished.
see ya
Avatar universal
thanks, seems like alot of differnt ways they handle.
30678 tn?1217992847
I just read what you said about antacids and riba, I was not told that, I've been taking acifex and my riba together in the morning, thats a no no?
Avatar universal
Dude Chill, I know about NOT to take antacids --BUT NOT FROM THE DOCTOR -he said to take and nothing about waiting(let's just kill him) I found out from reading this forum, I think it was Jim.

You are right about about my appts and everything but I only have 8 weeks left and should only have to see his sorry a$$ 2 or maybe 3 more times, same with the blood work, so that's $66 no biggie. But should say something, who to the doctor or the billing people or Lab or ins.??
Avatar universal
She meant pcr test. I was shocked that she said every week. Just hope insurance does pay, but she claims she hasn't had a problem.

thanks for explaining about the hgb, I will discuss it with her.

Avatar universal
Lucky lady, be thankful you've found a doctor who will do weekly PCRs until you clear. That tells me a lot. You might still ask her the sensitivity of the test she will be using. After you start treating, the test should have a sensitivity of 50 IU/ml or less.

Ideally, you'll be taking a test like Quest Diagnostic's Heptimax that goes all the way down to 5 IU/ml. As I mentioned, I never had a problem with insurance over the frequent PCRs.

-- Jim
Avatar universal
Okay I get it about the antiacids.  HOw about allergy pills (over the counter).  Until it frosts It drives me nuts.
Avatar universal
Just because they bill me  doesn't mean I have to pay it, although there is probably some loophole and I could be wrong-These charges are on my EOB's!!!

I go to Dr. and Lab on different days a week apart. First lab then Dr. I guess so doc will have the lab to look at so he can OK meds for another month.

A co-pay is for when you see the Doctor and I don't think they can legally charge anything else if hes in my network and accepts my ins. I think the term on the EOB they used was "eval."or consult or some other such nonsense. My lab is in my network too and should be covered So why the $22 charge?      
This F#ck won't even DX my gastro problems and hes a freakin GI!!! I mentioned some of my symptoms that are IBS'ish and he said to take an antacid as I saw the back of his head walking out the door. I guess a separate appt with separate co-pay to address this issue even tho it TX related!!

We can go into a frenzy together.

I know I don't have the best deal for my drug co-pay but my ins is only $250/month beat that.  na-na,  na-naaa-nahhh
Avatar universal
You DOO know NOT to take the Riba with the antacid RIGHT!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Please say that jerk didn't not tell you that or I am going to lose it!

Make sure it's at LEAST an hour apart at LEAST.  Something about one of the compounds making the med not work and also the antacid COATS your stomach.....so how can the riba get IN to the blood stream!

I don't understand how he can even BILL YOU!  Nobody bills me at the medical group I go to and if they did I'd laugh at them - I've NEVER heard of a co-pay for bloodwork like that.

I'd tell the doc - write the script for the med, we'll do the bloodwork at THAT time while I am there and then YOU READ THE RESULTS THE NEXT DAY and if anything is messed up...give me a call.  If you are in network it won't cost you a thing - worse come to worse stick .50 cents in a pay phone but you AINT billin' me $22 to come BACK!

Avatar universal
Do you mean a weekly *PCR* or weekly blood tests? Big difference because the usual weekly blood tests are enzymes, CBC etc, and do not include the PCR (viral load) test. I would definitely clarify with her.

If she actually means weekly PCRs, then you have found yourself an excellent doctor, but to my knowledge, you'd be the only one here -- other than myself -- that had weekly PCRs. In my case, my doctor tested viral load weekly until I cleared at week 6, and then suggested monthly PCRs after that. Insurance covered everything without a problem. If she didn't mean weekly PCRs, at least push for a 4-week week PCR in addition to the usual 12-week.

Regarding hemoglobin (hgb) during treatment. One protocol is not to administer the rescue drug Procrit until hgb hits a certain number which is often hgb 10.

However, the more agressive treaters understand that the absolute number is only one indication of anemia and often more important is the *rate* the hgb drops. For example, if you start out (pre-treatment) with hgb 15 and drop 2-3 points within the first three weeks, your absolute hgb would be above ten, but because of the fast rate of decline, it's possible you could be huffing and puffing and require Procrit. In my case, my pre-tx hgb was 14.8 and I ended up in the ER with hgb around 11.4 within a 2-3 week period. I ended up on Procrit for the rest of treatment. It appears from what you write that your doctor understands this, but always best to stay on top of the situation yourself. Anemia can hit VERY fast. One day you're OK, and the next can hardly cross the street. Trick therefore is to be as proactive as possible and stay ahead of the anemia curve by taking the Procrit timely if needed.

-- Jim

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