Topic: Help - How do you keep Insurance from knowing your meds are for Lyme so they'll pay?
Judie
Frequent Contributor (1K+ posts)
Member # 38323
posted
I'm on medicare and have the opportunity to take my husband's insurance which has a much better drug policy in terms of the cost of meds, but MUST decide in the next day.
I was fortunately warned by another person on here who had the same insurance company that once they found out their meds were for Lyme, he was cut off of treatment.
Is there any way to prevent the insurance company from knowing why I'm getting a ton of antibiotics?
I already see an out-of-network LLMD and pay out of pocket (I plan on NOT submitting the superbills at this point).
The insurance even has literature quoting Wormser on Lyme policy (stating they won't pay for more than 28 days).
I don't know if I should take the risk or just stick with my Part D which has been covering less and less.
Posts: 2839 | From California | Registered: Jul 2012
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BoxerMom
Frequent Contributor (1K+ posts)
Member # 25251
posted
I have this insurance and they've never squawked. And my DH and I are both treating.
I think a lot depends on how individual and group policies are administered. DH works for a huge international company, so our claims don't seem to stand out.
And we've only taken orals, so no IV charges.
Oh, and we have a completely different company for Rx meds. Caremark/CVS. Maybe that makes the difference.
You can't know ahead of time how this will go. Make your best decision. Maybe they won't ask for records. I'm positive for many co's and opportunistics, so I'm not too concerned about the dreaded Lyme word.
Judie
Frequent Contributor (1K+ posts)
Member # 38323
posted
Hi Boxermom,
I think that may be the issue. The RX and the medical will be combined and it's the same company.
His benefits only offer one insurance company for both medical and drugs.
That's what scared me.
When I do the Medicare calculator if I just do part D, oral meds for me will jump to over $1000 starting in March and beyond (and that's just for doxy, generic ceftin and nystatin).
Posts: 2839 | From California | Registered: Jul 2012
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BoxerMom
Frequent Contributor (1K+ posts)
Member # 25251
posted
You've got to be kidding!!
I would roll the dice with United for generics. Shoot. Our copay is $5.00 with Caremark.
You would pay less buying from India or Mexico.
Honestly, you have to be a Senator to get healthcare anymore.
Judie
Frequent Contributor (1K+ posts)
Member # 38323
posted
It's totally nuts and I need to decide by tomorrow.
I'm not kidding. I'm playing with the Medicare calculator right now (anyone can compare plans for Part D, you just enter in your zip code).
There are 30 plans in my area and ALL jump to over $1000 in March/April because you reach the limit referred to as the donut hole, then it's out-of-pocket for several months.
There's 1 NEW plan from Cigna that says they'll cover you in the donut hole with a premium of over $100 a month. There aren't any reviews and another Cigna plan even had a caution sign next to it from low ratings.
Read Droid's post here (I got more info and it sounded like a nightmare with UHC):
posted
Judie - I have UHC and they've never questioned my oral abx. The letter you posted is about IV abx (parenteral).
I had BC/BS the first four months on IV. They approved my IV "indefinitely" because of co-infections, but unfortunately I was forced to switch to UHC last January.
UHC wouldn't pay for any more IV (had to start paying cash) but they haven't denied me any orals. Right now I'm taking five for Lyme, Babs, and Bart. They haven't questioned any labs either, I get blood drawn every month. They know I'm taking this stuff for Lyme, one of their nurses calls me every so often to see how I'm making out.
I hope you feel better, these are scary times.
Posts: 99 | From Cali | Registered: Dec 2011
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Judie
Frequent Contributor (1K+ posts)
Member # 38323
posted
Hi Southpaw,
Thank you soooooo much for posting your experience and making sense out of this, especially with your IV experience. I haven't had to do IV yet and I have no idea what my LLMD has planned for next year.
That's amazing that a nurse calls you to check on you.
Do you submit superbills to UHC too or is the doc in network?
I did decide to try my husband's insurance since the meds are so much cheaper than what I'm paying now.
I know I'll be on orals for awhile.
Posts: 2839 | From California | Registered: Jul 2012
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posted
I pay cash for my LLMD. She doesn't take insurance. I could submit the bills as out-of-network but would never come close to my out-of-network deductible.
My primary care doctor, neurologist, and head-shrinker (for years they said my Lyme and co-inf symptoms were "mental") are all in-network. I also get an ultrasound of my liver every couple of months without any trouble from UHC. I think I'm done with ultrasounds, my liver problems finally cleared up.
I think the nurse is part of their "preventative care" effort. She called to say she was my "case worker" or something like that. UHC has a 24 hr nurse line we can call anytime with questions.
Meds can be the tricky part so here's what I found.....your experience may differ but for the most part:
UHC and most other insurance companies follows the 28 day rule for IV abx. Sometimes you can go longer based on co-infections as I did with BC/BS. UHC used to do that as well but changed their policy in late 2012.
Labs and Rx are at the discretion of the doctor so don't think insurance co's have the same pull when it comes to bossing doctors around.
A PICC can get expensive, I hope you don't need to get one. Once UHC cut off my Rocephin I started buying through WalMart Specialty Pharmacy. They're not cheap either but (something to think about. My LLMD negotiated Lower rates for me, knocking my monthly IV down to $266/mo from $1200/mo.
I hope you feel better. I'm
Posts: 99 | From Cali | Registered: Dec 2011
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map1131
Frequent Contributor (5K+ posts)
Member # 2022
posted
Southpaw, Humana my primary insurance is trying hard to get me to have this "nurse" to take care of some of my healthcare.
I've been fighting it. One I don't run to my PCP unless I've had months of continual sx that have me concerned ex: for 6 mths I've been getting these very large black/purple bruises on my torso.
I've never had these type bruises. Yes, I have bruises on arms and legs, because I run into walls & doors a lot. But the torso is not explained. My guess is babesia?????
My concern was to eliminate the "cancer" thing and we did that with blood work. So, everything really does come back to lyme & co, with me anyway.
If Humana can provide me a lyme literate nurse, I would be glad to see them??? Yeah. My PCP has been with me for 15yrs, he called it lyme from day 10 of illness.
Anyone see any advantage to using these nurse/case workers with this illness?
Pam
-------------------- "Never, never, never, never, never give up" Winston Churchill Posts: 6478 | From Louisville, Ky | Registered: Jan 2002
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map1131
Frequent Contributor (5K+ posts)
Member # 2022
posted
Judie, I'm glad you finally got this stressor out of your life. This should not be such a major life event for us that are so sick.
It wouldn't be if we had something else besides the one thing that is sometimes said not to exist, chronic lyme and chronic co-infections.
Boxer, everyone is talking about cleaning The House out in this next election. So you could easily win your state.
Pam
-------------------- "Never, never, never, never, never give up" Winston Churchill Posts: 6478 | From Louisville, Ky | Registered: Jan 2002
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Judie
Frequent Contributor (1K+ posts)
Member # 38323
posted
How does a nurse/case worker even enter the picture?
map1131
Frequent Contributor (5K+ posts)
Member # 2022
posted
Oh Boxer can I stand on that platform and raise He!! with you? Pretty please?
Judie, yes, I've had calls, emails, letters. To date I won't even talk to them. But I think I call and play with them one day.
Ask them if they have a lyme nurse expert for me to work with, prefer one that has lyme or child with lyme or spouse with lyme?
Somebody that gets it? Yeah, only if it's my lucky lucky day. I'll play the lottery that day too.
Pam
-------------------- "Never, never, never, never, never give up" Winston Churchill Posts: 6478 | From Louisville, Ky | Registered: Jan 2002
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Keebler
Honored Contributor (25K+ posts)
Member # 12673
posted
- Case workers for insurance companies are often not the "best friend" they want us to think they are.
Oh, I know each one really has a good heart and they do mean well and generally do well for the typical patients. Personally, all very find people, I'm sure.
But they are hired as a look out for the insurance companies - to keep an eye on you to control their costs.
Be very careful with what you share during any conversation with a case worker (or whatever title they may have). -
Posts: 48021 | From Tree House | Registered: Jul 2007
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map1131 - the nurse isn't Lyme literate, she's a regular nurse. She called and asked a bunch of questions about general health and what my meds are for. I gave her the minimum and left it at that. The only medical person I trust right now is my LLMD.
Posts: 99 | From Cali | Registered: Dec 2011
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Judie
Frequent Contributor (1K+ posts)
Member # 38323
posted
"Judie, I'm glad you finally got this stressor out of your life. This should not be such a major life event for us that are so sick."
Well, it turns out my husband's insurance won't cover bicillin shots for ANY issue. His work opted out of it when they made the contract.
Wish I stuck with medicare. I'm learning that medicare is actually pretty good for Lyme meds since Part D is with a different company and they don't even see the medical bills.
I now have to ask my LLMD to rewrite my last super bill without the Lyme code on it so I can hopefully get reimbursed.
Posts: 2839 | From California | Registered: Jul 2012
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