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» LymeNet Flash » Questions and Discussion » Medical Questions » IV abx. How long on and does bcbs va cover extended use?

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Author Topic: IV abx. How long on and does bcbs va cover extended use?
Aimee
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Seein the llmd Thursday. Fairly sure we will discuss IV therapy. How long have you all had to stay on IV? I've been treating with orals for 3 years.

Any idea if bcbs of va is Lyme IV friendly and if so for how long? Hoops to jump through?

Thanks,
Aimee

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sammy
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Their (BCBS) medical policy was 4wks for documented neuro and cardiac Lyme.

I appealed for 2yrs (for unpaid bill that they had given me a pre-certification for) with the help of many doctors and lawyers. In the end they paid for 7wks Rocephin total. (The bill was for 3mo.)

Your individual plan may vary. Request the medical policy before starting treatment.

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Aimee
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The 4 weeks is what I keep finding on their website.

So you appealed for a 2 year term but they only approved 7 weeks and it took a lawyer to get that?

I feel like this isn't going to go well.

Any idea how ridiculously expensive IV's are out of pocket? I'm sure it will be too much for us to swing but I'd like to have an idea anyway.

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faithful777
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I have been on IV 5 months and so far have 3 months paid by insurance. The infusion company waits for 6 weeks after I order to submit so I still have two IV orders that are going to be submitted.

We will see if they pay for any more. Hoping anyway.

--------------------
Faithful

Just sharing my experience, I am not a doctor.

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Aimee
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faithful - was this thru bcbs?

i dont' understand the way the system works - I just want it covered for as long as it takes!

were you on oral abx before iv? have you noticed significant immprovment?

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poppy
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That's the problem. Before you find out that they won't be paying, a big bill can be incurred. There have been cases when it was pre-authorized, or at least the patient thought that was the case, but they still would not pay.

I was worried about this, so I stopped using the more expensive home health service and went with a mail order pharmacy and had a doctor's order to learn how to do dressing changes and infusion by myself, before they stopped paying.

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Aimee
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so is it the actual antibiotic itself they don't want to pay for or the home health???
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poppy
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Home health infusion services, which means the meds and supplies, and in some cases the infusing and dressing changes. Perhaps any blood tests.

What I meant was that I switched to a lower cost infusing method, in case they decided not to pay, and I got stuck with the bill.

These days it is common to have IV payment by insurers cut off after a month. It surprised me to hear that someone has had them paying for three months. Not typical.

You may get more specific info on the situation in VA by contacting NatCapLyme or attending one of their support group meetings.

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Limeaid
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I had BCBS Premera, and they paid for 7 months IV Rocephin with supplies, and home health. An RN from BC would call me once a month to check on me and how I was doing. I was lucky, and never had a problem with their coverage. They may have paid for longer, but I stopped treatment because it wasn't providing much benefit to me. Hope that helps!
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poppy
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When was this limeaid? They seem to have gotten more restrictive in the last two or three years. There is also a difference between BX organizations. Some are for profit, some non-profit. And they all seem to have different rules.
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Limeaid
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It was from September 2010 to April 2011. They also paid for a month in 2009 without conflict. Hope you are able to get it covered!!
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Aimee
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Limeaid - that is really good to hear. I guess I will be calling the benefits office to see if I can nail down what they will and won't cover and for how long.

So frustrating that everything with this disease is difficult. Sure wish insurance would let doctors do their doctoring!

Curious to hear from others who have had bcbs and successfully gotten more than 4 weeks of IV abx. Please keep the responses coming, it's very helpful information

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sammy
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Aimee,

Here's what happened to me. My LLMD wanted to put me on IV antibiotics. I insisted that he get pre-certification to make sure that my ins would pay. Was told that IV abx for infections were fully covered...

I was on the IV antibiotics for 3mo. I called every week before my next shipment to make sure that my ins was paying. Was always reassured that everything was fine, we had the certification, no worries.

Then I got a call one day while I was at work, my insurance had not paid for the past 9 wks of treatment. They were not sending my scheduled shipment of antibiotics.

They said that I owed approx. $20,000 (this was the reduced cash price). I tried appealing with the help of lawyers and a team of doctors. The appeals process went on for 2yrs, finally it was reviewed by the state board of ins. Final decision was made in favor of the ins co because medical policy followed IDSA guidelines.

So after all the appeals my ins covered 7wks of IV rocephin treatment. I was left with 8wks of of unpaid fees. Final cost was about $20,000. Sad. (cannot pay that [Frown] )

Faithful, as your friend I would caution you to please be careful. What will happen if you ins co decides to stop paying? You will not know until you have racked up over 2mo of overdue bills with the local infusion company. Unless you have a prearranged agreement with the home health/infusion company, you will be held responsible for those overdue bills. Please don't let that happen!

We should not have to think about these things. If we had any other illness or disease, our IV treatment for the infections would be fully covered. We would not have to worry about WHEN our insurance will stop paying. Ins would continue paying until our infections were gone or our doctors said we could stop treatment.

We do not live in an ideal world. Ins WILL stop paying at some point. Please be prepared, talk with your local home health/infusion company, see if they will work out an affordable payment plan. Or shop around for better prices at different pharmacies like Infuserve America.

http://www.infuserveamerica.com/

Sometimes your insurance will refuse to pay for IV antibiotics up front but they will reimburse you for some of the cost. Infuserve will submit all of the the necessary paperwork to your medical insurance for you.

After that rocephin nightmare described above, I turned to Infuserve for my IV antibiotics. They are much more helpful and trustworthy than any other infusion company. My out of pocket cost is less with Infuserve than my copay was with the home infusion co! Wish I had started with Infuserve and avoided the 2yrs of heartache and continued stress (from the huge outstanding bill).

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WendyK
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3 1/2 months so far with no problems that I'm aware of. I sure hope I'm not in for an unexpected bill!

--------------------
Wendy

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faithful777
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I pay cash and then my bill is submitted to insurance. No surprise bills are coming my way as I pay first then hope to be reimbursed.

If you work with Infuserve, you pay first and then they file with your insurance. They at least make it affordable for me to be on IV. My husband also has Lyme. He is only on orals and not getting better yet.

My insurance makes me pay 10% of nursing visits which are $16.50 out of my pocket for each visit until I meet the in network coinsurance. My in network and out of network coinsurance was met by February 2012 with all the expenses I have with out of network doctors. All deductibles were gone before that.

So by February, I spent $4,000 out of my pocket and used up $3600 in my medical spending account.

When there are two people in the same house that are sick, the dollars go up quickly. I don't know when the reimbursements will stop, but I hope they will continue. I didn't get pre-authorization when I asked, because my insurance company said basically, we might pay and we might not. They wanted me to do it and then submit. Go figure.

So I knew this would be cash out of my pocket for the foreseeable future if I started the IV. Getting paid anything back was a surprise.

--------------------
Faithful

Just sharing my experience, I am not a doctor.

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cht girl
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Insurance paid for almost 4 months last year, and paid for 5 months this year. I called my home infusion company and negotiated on out of pocket price comparable to what Infuserve and the other mail order pharmacies quoted me, so when insurance stopped paying I wasn't stuck with a huge bill, I paid $10 per dose of IV antibiotic $10 per day for all supplies/dressing changes. I also had the DR. send an order for my husband to be trained in PICC line dressing change so I wouldn't be stuck with a weekly nursing home visit charge. I have not paid over $600 per month for IV meds/supplies when I had to start paying myself.

I have made such improvements on the IV that 2 years of orals could not do, it has been worth every penny.

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lightfoot
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The unfortunate fact is the insurance companies can use the IDSA Guidleines as STANDARD OF CARE. My story cost me 30,000.

--------------------
Healing Smiles.....lightfoot [Smile] [Smile] [Smile]

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faithful777
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Not all LLMD's will let you go solo without a nurse checking in. Mine won't even though I can access my port myself.

I never paid over $800 for everything in a month and infuserve prices for Rocephin with an elastomeric device is $699 with all supplies included. They are great at billing the insurance company and have been extremely helpful trying to keep costs down.

Can't get B12 cheaper anywhere else.

When your drugs change, so does the price. I am not on Rocephin anymore and Clindamycin is much cheaper than Rocephin.

Everyone should do their homework in their area to see if they can get the cheapest price. Infuserve does pay attention if you get something cheaper elsewhere most of the time, but you have to do what works out best for yourself in what ever state you live in. You have to save money where ever you can.

--------------------
Faithful

Just sharing my experience, I am not a doctor.

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Aimee
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Just got picc today. Insurance will cover 28 days only. And that's it. No negotiating. So I would love more info from you who have used infuserve.

I am likely liking at 4-5 months of IV therapy.

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