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Infusions and insurance - pharmacy or medical?

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Crohn's Disease
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Posted 4/13/2016 12:29 PM (GMT -5)
Well my employer is switching the pharmacy benefits manager part of my health insurance from Aetna to Express scripts. Aetna will continue to be the medical insurance provider. So I'm freaking out at the potential for changes, or just things they will mess up in the transition. I receive Entyvio infusions, but they have always been paid and priced through the medical part of health insurance, not the pharmacy. So my first thought was that nothing should change with that. But Express scripts lists Entyvio, Remicade, and other infusions in their formulary and other literature. My company's HR is not answering questions. So I just wanted to know from the people here, do your infusions (be it Entyvio, Remicade, or something else) get covered by your pharmacy benefit or your medical benefit? Bonus points for anyone who replies and has Express scripts.
Posted 4/13/2016 12:32 PM (GMT -5)
Mine is covered by my medical benefit because I get them out of my doctor's office, so it's considered part of a medical procedure, the way anesthesia would or IV meds in the hospital. I think that pharmacy ones would be Humira, etc. that you pick up from the pharmacy or if you do infusions in your home and medicine is shipped to you.
Posted 4/13/2016 2:10 PM (GMT -5)
When I took Remicade th mail order pharmacy of my insurance company made my GI's infusion center get the Remicade from them. I was not covered if the dr used his own supply and billed my insurance.
Posted 4/14/2016 4:54 PM (GMT -5)
My son's is through the medical portion of his insurance. I was told by insurance that if it went through a speciality pharmacy it would not be covered? We have Blue Cross / Shield and have signed up with remistart to help with the costs. Although we have a low deductible so after one infusion Blue Cross / Shield pays 100 percent!
Posted 4/21/2016 5:09 AM (GMT -5)
Get it in the Drs office, get remistart. hospitals overcharge. i got stuck with 10k + at the hospital and very little at the drs office with remistart. the hospital waited to long to send out bills, remistart wanted it within 30 days.
Posted 4/21/2016 6:51 AM (GMT -5)
Infusion treatments apply to the medical portion of your benefits. If you were to receive injectibles to your home, that would fall under the Specialty pharmacy benefit.

Please also remember that there is a combined maximum OOP expense for Medical and Rx at $6,850 for 2016 (unknown what 2017 will be). Even though you have a PBM that is different than your medical carrier, your OOP expense combined still can not exceed that amount. I recommend watching that if you are close to the limit as having two separate providers can lead to information sharing issues and timing.

ps...I do work for an insurance carrier. I am not advocating for any carrier, type of coverage. Just providing information that I see daily.
Posted 4/21/2016 3:24 PM (GMT -5)
Thanks for the info. My company had an information session yesterday with a representative from Express scripts and from the benefits management company. Both said infusions will remain under the medical benefit, which is good for me. Habs, thanks for the tip about watching the coordination of the deductible and out of pocket limit between Aetna and Express scripts. Yes, I'm sure they will mess that up!
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