Insurance policy is so stringent (impossible to meet their criteria) for IV abx. Has anyone had success getting treated and have coverage with aetna? How about long term oral abx from out of network LLMD? COncerned that with all of my stuff, and kids, that they'll try to limit treatment -- then, what do you do? anyone have any experience with aetna and how long did it take to get it resolved -- best route to take -- I am so sick that I can't advocate or fight them and haven't been submitting out of network stuff
Posted by susscho (Member # 7429) on :
oh yeah, I forgot to ask -- does Igenex test results mean anything to insurers? I actually had so many positives on Igenex test that I met CDC requirements as "positive" -- didn't know if Aetna considered Igenex lab experimental -- did not get an Elisa since useless -- but that is required for their policy -----
Posted by amkdiaries (Member # 7035) on :
Yes I have Aetna and it has been one long fight trying to get them to cover I.V. They initially covered it for 6 weeks but I was on for two years and am currently talking to an attorney about the matter. You might want to check into your pharmacy benefits to see if the I.V. is covered there. I did that for a while until they caught on and pulled the plug on that. You will need a letter of medical necessity from your doctor to file an appeal if coverage is denied but don"t give up. I didn"t.
Posted by susscho (Member # 7429) on :
How were you on for 2 years -- without coverage? after the 6 weeks, what happened? The pharmacy benefits are 3-tiered -- for cost to me.
Is your doctor out of network? Does the letter of medical necessity valid to them if the doctor is out of network? How can you get I.V. treatment if they won't cover it -- did you have a MRI showing something? sorry for the incoherence -- Email me if you can...thanks
Posted by amkdiaries (Member # 7035) on :
After 6 weeks, I paid for medication out of pocket with my credit card and submitted claims to the pharmacy dept. for reimbursement. They paid since the drugs were ordered by prescription but after about a year they stopped and then I started to submit claims to the medical side of Aetna for the drugs obtained through the pharamacy, This varies according to the type of plan you have with Aetna. Since the drug store is out of network with Aetna I only get back 70% of my costs for medical supplies and drugs. Yes you can get treatment with an out of network doctor but only if you have out of network benefits with your plan. I did not have an MRI that showed evidence for Lyme but had several positive blood teats and soo many symptoms that the doctor recommended treatment and I feel I.V. is the way to go for me since I could not tolerate high doses of orals. It is a very expensive form of treatment but there are ways around it like getting your own medical supplies instead of using a home health care company. It also depends on whether or not the doctor will let you do this since it is uncommon for patients to handle their own drugs and supplies but my doctor had no problem with this. I could not afford home health care that long and most of their prices are heavily padded. Hope this helps!