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Remicade copay?

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Ulcerative Colitis
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Posted 11/18/2011 10:36 PM (GMT -5)
My wife is in the hospital and they are discussing starting Remicade.  We have a really good private insurance co. that generally covers everything.  The doc had a hard time getting the insurance co. to approve it even with a letter of necessity.  They said they would approve it while she is hospitalized, but could not guarantee what the copay would be once she gets out for further treatment.  From what I've read the copay can be very high. We can't afford it; we will lose the house.  How do you get it classified as a chemo treatment?  From what I've read, then the infusion would be covered. 

How does everyone afford this?

Posted 11/18/2011 11:10 PM (GMT -5)
Check the coverage levels for your plan's specialty pharmacy category. That's what Remicade is covered under. Make sure you also look up your plan's out of pocket max. That is the maximum amount you'll pay for health care in a plan year. (excluding deductibles and copays).

Also, make sure you look into the remistart program. The manufacturer will reimburse you up to $4400 for your out of pocket costs in your first year.
Posted 11/19/2011 7:05 AM (GMT -5)
Thanks Indycat23. That's the kind of info I need.
Posted 11/19/2011 9:33 AM (GMT -5)
It also depends on how it will be billed. When it was being billed as an office visit to the doctor, I only had to pay an office co-pay. When they decided to create an outpatient clinic and bill it as that, I had to pay 20% (waiting for the rebate from Remistart).
Posted 11/25/2011 11:28 PM (GMT -5)
I had experience similar to bookworm21. Only remistart isn't paying. I believe the Remistart people told me that they will verify your benefits for you. Be sure to check it out before the infusion. I paid 20 for infusion at doc's office. I had it in the outpatient area of a hospital and my co-pay was over 700! Still paying that off.
Posted 11/26/2011 2:32 AM (GMT -5)
With my insurance they told me that I had to have it administered in the hospital instead of my doctor's office (even though he did offer treatments there) because they had a bigger budget amount for it to be given at the hospital than at the doctor's office.

Also, my insurance NEVER informed that they had Transfusion Centers that I could go to and have it administered and only pay my $20. copay per treatment!!!!!!

I had an Earth Angel mention that to me at the doctor's office when she realized what my insurance company was doing to me! Call them and ask about that!

Isn't it terrible that they never once mentioned this to me as an option but once I asked them if they had centers like that where I would be covered they said YES and it was located not too far from my home either!

Hope you feel better. blush

Posted 11/26/2011 9:15 AM (GMT -5)
Dr J--yeah, my co-pay is not $800 instead of $30. And Remistart will only cover the cost of the medication, not the administrative fees that come with the infusion. So I'll still have to pay about $200 per infusion. Unfortunately, it seems that all of the places in my area for infusions are hospitals and outpatient clinics. Anyway, I love my GI and infusion nurse and the clinic is within walking distance, so I'll just have to deal with it.
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