posted
I have a good health insurance plan through my work and am able to get a high percentage of out of network costs covered after I reach a deductible (which I have already reached once I file for it). I am planning on filing the paperwork as I would then save substantial money for dr's appts and testing this year and possibly last year if I do so retroactively. However, I don't know if this might open a can of worms for me creating a greater risk of losing prescription coverage if I go on ABX long-term, which is looking like more of a possibility starting in the next few months.
I had 2 prescriptions filled for ABX last year (the prescriptions were separated by a few months) and both were covered by my insurance as I only paid a minimal copay for each. Both of these prescriptions were prescribed by my LLMD, who is not in network, and for whom all appointments I pay out of pocket for. Some of the testing my LLMD ordered was also covered (like the CD57 labcorp test).
I know my dr's name is naturally in the insurance company's records for my previous ABX prescriptions and would be on any future prescriptions if I started up ABX again. So it may be a moot point, and I'm inclined to think that if the insurance company is going to stop covering ABX after a couple months of me starting up again, they would have my dr's names on the prescriptions anyway and would do so regardless of whether I had already filed this paperwork for my dr and the other lab testing, right?
I appreciate any advice on what to do in this regard. The last thing I want to do is make it more likely for me to incur very high costs if I go on ABX down the road in order to save some money now. But of course, if it's not going to make a difference in affecting whether or not I might get cut off for ABX later, then I absolutely want to save the money I can now with the out of network coverage.
Posts: 43 | From NJ | Registered: May 2007
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Tincup
Honored Contributor (10K+ posts)
Member # 5829
posted
Charlie...
I can't say which idea is better and how your company will react... but I am ... as we speak... working on a legal document for folks to send to their insurance companies that should help.
Just did editing work on a generic one yesterday that will be published .... and will write one based on that today... (am suppose to be doing it now)... for patients to use.
Keep an eye out for it to be available soon... ok?
Tracy9
Frequent Contributor (1K+ posts)
Member # 7521
posted
Insurance companies have different policies and practices, so it depends on the carrier. Often the larger/largest health providers offer the most restrictive coverage.
With that said a person could easily be infected with Lyme more than once. Also co-infections require treatment which have different standards of care from Lyme.
You can call your insurance company and ask them what the coverage and benefits would be if your Dx was Lyme disease. I dont know the ICD/9 code but you could look it up. This is the Dx code that the insurance companies use to process claims.
13 years Lyme & Co.; Small Fiber Neuropathy; Myasthenia Gravis, Adrenal Insufficiency. On chemo for 2 1/2 years as experimental treatment for MG. Posts: 4480 | From Northeastern Connecticut | Registered: Jun 2005
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posted
Alright, I did some more thinking on how things work, and I'm guessing flags are often raised within insurance companies through the following scenario:
1.) A person has prescriptions filled for ABX for several consecutive months.
2.) Insurance companies then look into seeing why these ABX are being prescribed, be it something they may cover like re-occurring sinus infections or something they wouldn't cover like lyme. If the prescribing doctor is in a database they have of "lyme" doctors, then that would raise a flag, and they'd pursue verifying the condition/medical illness being treated with these prescriptions.
Or they could simply just contact the dr. right off the bat to verify the illness being treated. Either way, I see it being just as likely for me to potentially face issues with coverage for long-term ABX if I don't file paperwork now for out of network coverage for my appts and labwork as it would be if I did. So I think I'm going to file the paperwork.
I'd still like more opinions on this for anyone who has knowledge or experience in dealing with related situations. I don't know all the specifics of what I would need to write down on these forms, which I need to request from my insurance company. I may still balk if I would need to put a lyme diagnosis in writing anywhere.
Posts: 43 | From NJ | Registered: May 2007
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sixgoofykids
Honored Contributor (10K+ posts)
Member # 11141
posted
Hi Charlie,
I don't turn in my medical bills because my LLMD is out of state for me and I only see him three times per year. With a $1000 deductible for out of network and only three appts. it's not worth the trouble of turning in the bills. The phone consults are not covered anyway.
I know someone else who turns in all their bills and even part of their travel expenses are covered.
I don't know if the insurance can tell who prescribed the meds or not. The only ones I needed prior authorization for were sleep meds and Levaquin for bartonella (so no red flag for Lyme).
My insurance plan says they can stop coverage for meds at any time for any reason, so I didn't want to do anything to jeopardize prescription coverage ... maybe turning in the bills would not have affected anything, but for the pennies I would get back, it was just not worth the risk.
I did get a letter from my insurance company asking if I had other insurance (presumably because I was getting prescriptions with no doctor visits from what they could tell). We just told them no. Nothing more was said.
For me, it's an out of state doctor ... so I may have had to fight for coverage anyway. In the beginning I was too sick to think about it and hubby was too overextended with taking care of me, the kids, his job, etc.
-------------------- sixgoofykids.blogspot.com Posts: 13449 | From Ohio | Registered: Feb 2007
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tdtid
Frequent Contributor (1K+ posts)
Member # 10276
posted
This is a timely topic since I just went out to do a search on where to turn.
As I have mentioned, I'm being referred to a new llmd after 19 months of orals which actually I never had trouble getting Blue Cross Blue Shield to cover.
But as far as IV, they say they will only cover one month of IV and I think we all know that isn't going to be enough.
I see the doctor on Monday and would like to know what I'm in for. Any help or guidance on how others get past the one month of IV?
Cathy
-------------------- "To Dream The Impossible Dream" Man of La Mancha Posts: 2638 | From New Hampshire | Registered: Oct 2006
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One suggestion one of my physicians made was to do the 30 days IV, go on orals for 30 days, then retest. If positive (Especially by PCR, which finds the actual bacteria), it gives good support for another round of antibiotics.
This came from a physician who accepts insurance for Lyme care, so it must have worked for him in the past.
Posts: 168 | From Delaware | Registered: Aug 2005
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