This is topic IV Rocephin Insurance question in forum Medical Questions at LymeNet Flash.

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Posted by davidx (Member # 8326) on :
This is a question to all those who have used IV rocephin (or generic) and have gotten it covered by insurance (or tried).

Is the issue with insurance with regard to just the medication or with regard to all the other stuff that come along with it (syringes, nurse appointments, etc)?

Before I start I want to be sure of what my insurance will pay for. Somehow I don't think it's as simple as calling up and saying "Hi, do you cover IV rocephin for lyme?"..or is it?

Any input as to what questions to ask my insurance company would be greatly appreciated. I just don't want any "surprises" after I start and when I go to refill.

Thanks very much for all the help. Sharing experiences here really helps people out a lot.

Posted by notkrazybrian (Member # 10621) on :
Posted by monkeyshines (Member # 6406) on :

While my insurance paid for it, they paid for everything; meds, supplies, and a weekly nursing visit to access my mediport. (Under my policy, paying for 'everything' means they paid 80%.)

But, I ended up going off Rocephin after only two months for 'administrative' (as opposed to medical) reasons. My infusion company forewarned me that 'many insurance companies limit IV therapy for lyme.' So I called and asked my insurance company whether I would continue to be covered if I continued the therapy past the two months I had already had.

I was told 'unofficially' that the standard of care for IV therapy for lyme is at most two months, and there's no proof that further therapy would help. I say unofficially because my insurance company's policy is that they can't answer questions about whether you need something and if they will cover it until you've already had it and a claim and substantiating paperwork have been filed.

Therefore, if I continued, I would not know until the infusion company submitted my claim and the insurance company responded whether I ALREADY owed $700 a week out of pocket.

I couldn't take the financial risk, being so far in the hole from this disease already. I literally went overnight from being on IV twice a day to not accepting my next shipment of supplies.

This is only my experience, and all insurance company's are different (including policies by employer within the same insurance company), so I don't mean to scare you away. But I think you are wise to ask up front. I think your LLMDs office should be able to help you navigate this!

Good luck,

Posted by JeffM (Member # 8919) on :
Your doctor's office should handle it.

My insurance company told them they would cover it 100%, then said they wouldn't cover it at all.

I ended up paying for the whole thing myself. It is not so bad now that it is generic.
Posted by davidx (Member # 8326) on :
Thanks for the responses. It seems as though I have separate prescription plan from my insurance plan so I called both tonight.

I called the prescription benefits company and asked them about rocephin. They said that there is no limit for that particular drug. They also said that no documentation is needed to have the drug prescribed or refilled. I told them about lyme and she didn't seem to have any rules regarding lyme treatment.

So I then talked to the supervisor to get her input. She went over the details and basically said that the plan I have does not limit rocephin refills and does not require physician documentation other than a prescription. It sounded like this prescription could just be filled at my local pharmacy. Does anyone know if this is the case?

Anyway, it just seemed too "easy" on the phone and I mentioned lyme several times but they kept telling me that my plan doesn't have a maximum for rocephin? Was I asking the right questions?

What is an infusion company? I thought once the line is put in you just pick up the prescription once a month and infuse once a day. Then a nurse comes to your house to change the dressing once a week. I guess all that stuff needs to be coordinated with the insurance company?

Anyway, any additional input from people would be great.

JeffM- How much did it end up costing you since the insurance did not pay for it?

Posted by Cobweb (Member # 10053) on :
My LLMD prescribed IV Rocephin for me.

The LLMD office called the infusion company.

The infusion company contacted my insurance company and reported back to me that my insurance would pay 80%.

I received a letter from my insurance company, so it is in writing, that they will cover infusion therapy for 999 days-contingent on receiving a new script from LLMD each month.

I have now been on it for about 4 months.

I started with peripheral IV's, temporary IV's that were placed in my arm , around my wrist usually, each week. Peripheral IV's are short term.

Then I got a picc line placed-for long term IV therapy. I like the picc line a lot better.

Bottom line- get it in writing. The doctor and infusion company set it up, each month. Supplies are delivered to my door, and a nurse comes out to see me each week-and they are also on call.

I made several copies of the letter from the insurance company-and made sure everyone got a copy.

I will tell you I have improved greatly with the IV Rocephin-

Warning-I did spend yesterday in the ER thinking I was going to die. I felt like I was having a stroke and a heart attack at the same time. ER doctors were concerned, and wanted to keep me.
But LLMD told them not to worry-it was only a herx! [Razz] I feel fine today- and she was right.

I got home around midnight (after 6 hours of cat scans and EKG's and blood draws and waiting )and ran my infusion. In fact I need to go do that now.

I guess to clarify even more-insurance is covering the medicine and supplies and nursing-all through the infusion company.

Good luck-I was really nervous before I started-Now I am so grateful it is available to me.

Posted by monkeyshines (Member # 6406) on :

I think most of us get hooked up with an infusion company by our LLMDs office. The infusion company basically does everyting once your LLMD has writtent the the Rocephin, mixes it in IV bags or balls, supplies the saline and heparin and other related supplies, and provides weekly nursing visits. They also bill your insurance company, and that's where problems may arise.

An alternative to the problem I just had with my insurance company is for me to buy the Rocephin directly from my mail order pharamacy, and then have the infusion company provide the same services they would if they were providing the drug and services and billing my health insurance company (i.e., mixing Rocephin, sending saline/heparin/line supplies). I would be billed directly by the infusion company for the mixing and supplies, but it's a relatively small amount. (The Rocephin is also dirt cheap this way...what an insane system!) I would either have to have my port accessed weekly at my LLMDs or pay privately for the weekly nurse.

So what you're talking about may be a work-around if you have insurance problems (in the above scenario, the only involvement of my insurance company is them potentially paying if I have my LLMD service my mediport rather than having a nurse visit).

If I were you I would start by asking your LLMDs office about infusion companies and their relationship with them. Let them do the legwork first.

Posted by timaca (Member # 6911) on :
My Insurance company initially denied my IV treatment. I fought it and won. They paid for 6 1/2 months of it.

Do a search here on lymenet for in the "general support forum" for "insurance appeals" using my member number and my letters to the insurance company should come up.


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