9 Comments:

That's just ridiculous. Have you seen the discussion over at alittlepregnant.com about insurance and RSV shots?? So far we've been lucky with Emma's RSV shots being covered by insurance, but it's taken two battles with the nasty virus --both requiring hospitalizations. I guess that shut them up.

Melanie
Mom to Emma 34 weeker 5/11/02

By  Anonymous, at 10:43 PM  

sigh. no, i hadn't seen the alittlepregnant thread.

what's all more exasperating is that odin qualifies for medicaid as a "secondary insurer" because he was born so prematurely. the only downside is that medicaid doesn't pay for home delivery. had we known that the new pbm was going to deny the benefit we would have simply gone through medicaid. one can only imagine what sort of nightmare it will be to try and get medicaid to retroactively reimburse for services already rendered. nice system we have here in the u.s.

By  e3, at 10:52 PM  

UNBELIEVABLE! For one thing...please explain why a single shot of RSV, home delivered, should cost 2500.00? That is ridiculous! Oh, but don't be discouraged about the health care in the U.S., if we had...oh, what's it called, (for lack of a better word) "community health" care like they do in England, little Odin wouldn't even be here. We know people in England who pay for private insurance just to be able to see creditable doctors! So please, let's be thankful we do have insurance that is paying the vast majority of the ridiculous cost of hospitalization! And we are able to seek Medicaid to cover some balances too. I think you'd have to agree it could be much worse!
Lori

By  Anonymous, at 9:53 AM  

If you can prove that the date on the caremark notice occured after the date of service (the date he got the shot) then, they should have to cover it. I'd give them total hell. Tell them, you're spreading the word of this asanine loophole to parents of preemies everywhere. We have a caremark Rx plan too. Bastards.

ITA that $2,500 for an RSV shot seems a little steep, but I have no idea what it takes to make the medicine.

By  Candy, at 11:15 AM  

Aha, I was also going to recommend the alittlepregnant discussion of same...what a bunch of counterintuitive, bureaucratic b.s. As for why the shot would cost an exorbitant $2500, click over to MedImmune.com, manufacturer of Synagis, other anti-viral and oncology drugs. Notice their "R&D pipeline," and how they are developing more than a dozen new drugs, with only 5 already on the market -- like most BigPharm companies, they finance development by passing the cost (and don't forget the marketing $$$, all the outreach to doctors, see rsvmd.com) on to the "consumer," which is either the recalcitrant insurance industry or, unfortunately, you. Yes, these are groundbreaking, lifesaving drugs -- but the company's #1 goal is to keep the shareholders happy, not distribute the drugs as equitably or cheaply as possible. I'm an intellectual property lawyer, and I taught a seminar on AIDS drugs covering these same frustrating issues...so many conflicting interests, and of course the patients get caught in the middle. Gaaahhh, indeed! Hang in there, though, e3 -- you can let out your PapaBear instincts by taking on the system a bit. :) m.

By  emily, at 11:46 AM  

i'm certainly not one to begrudge the fantastic healthcare system we have here in the u.s of a. since it is very much responsible for how well odin has faired. but there's no denying that it sucks to be on the receiving end of the cost benefit analysis that results in insurance companies deciding that it's more affordable to pay for the hospitalization of x number of micropreemies due to complications related to rsv than it is to pay for y doses of prophylaxic administration of the drug. if you read through the alittlepregnant thread you'll see one parent who commented:

"My son, who was three weeks early, released from the hospital like a full-term baby, contracted RSV at 6 weeks old. He had to be life-flighted to Pittsburgh Children's hospital and was on a vent for two weeks. The doctors told us there was a very real possibility we would not be taking him home. Thankfully he pulled through and is 2 now and a terror...HOWEVER, how can insurance say it is cheaper to hosptialize the child rather than pay for the Synagis? I know for a fact that our stay at Children's was over $300,000. Our helicopter ride alone was $10,000."

while i can understand the economic equations, try putting yourself in the shoes of parent who had go through that experience. it's tough.

lori, you're right, it could be much worse ( for us at least ). we are fortunate to have medicaid as a backup insurer. but still, it seems obnoxious to consider that there are people who don't have medicaid as a secondary insurer whose insurance won't pay for rsv who have to decide if it's "worth" going $15K-20K in debt for a single "season" of rsv shots ( our $2,500 bill per shot will increase as odin gains weight and he'll need at least 6 shots ) versus the risks of a potentially fatal infection.

By  e3, at 10:52 PM  

Eric,
I agree, it is totally OBNOXIOUS! Really, I could not even imagine coming up with the money to cover it all! I remember after the birth of my second son, who is 12 now, we had just moved back to Michigan, new job for my husband, I wasn't working...we were broke! Our balance of the hospital bill was nothing in comparison to yours. But it was huge to us at that time. Anyway, I agree with the idea to FIGHT!
I used to do insurance billing for medical doctors and it really is quite fun to give insurance companies a run for their money! :o)
My advise...get all your ducks in a row. Write it all down so you have it in front of you when you call. TAKE NOTES WHILE YOU'RE ON THE PHONE! Make sure you get the person's name to whom you are speaking with, write the date and time you spoke to that person and when you hang up, write yourself a summary of your conversation! This has been a huge benefit to me even now just fighting for payments for my family. And most importantly, go higher in the management level if necessary! Show them you mean business!
I'm routing for you!
Lori

By  Anonymous, at 8:00 AM  

I am a now former Caremark employee and have a little bit of advice. First, make sure it isn't supposed to be covered by your medical carrier (United Healthcare, First Health, Coventry, etc.). The majority of all meds, including shots, are not the prescription side but the medical side. If that isn't the case, call customer care at 800-213-0879 or the number on your card and see if the appeals process is available for you. In your situation, the appeal would be covered.

By  Anonymous, at 11:28 PM  

As a current employee of Caremark, I thought I should inform you that it is your company that makes the list of medications that are covered or not covered. As the previous note was put in, I thought I would let you know that if you are indeed asking for an appeals, it is not Caremark who approves or denies, that it forwarded to your plan, or..your company who in turn gives it to Caremark to do the dirty work. Any copay or plan issues you are having are most likely set in the contract that your company made with Caremark. They make the rules, we just follow em. I would say if you still don't get anything done, you might want to call your benefits office :)

By  Anonymous, at 11:09 AM  

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