Insurance Coverage for Remicade

After my son's last infusion, I was notified that the insurance will no longer pay for the infusion to be done on hospital property and must be done at an out patient lab. Son's GI is not comfortable with an out patient lab and has discussed with the insurance company but they are holding their ground saying it's too expensive on hospital property. I was never notified of the new policy and either was my doctor. Discovered the issue when the last infusion was denied. (It's since been covered.) The out patient labs are further from my home and have restricted M-F daytime hours. In the past his infusions were done on Friday nights or the weekends. (My son is a high school senior.) I am filing an appeal with the insurance based on distance and my son's school schedule but wanted to know if anyone had a similar situation and could offer some advice.

You might look into a program called Remistart. You can do an online search.

Insurance covers the drug not the administration of the drug on hospital property. It's too expensive. I thought Remistart was for the drug itself?

You are right. I am sorry.

I am going to tag Clash.

More and more insurance companies are pushing for outpatient infusions centers
Which are cheaper but not equipped to handle anaphylactic shock which can only be handled in a hospital .
Regardless of schedule
The risk of anaphylaxis is very high with remicade which is why it's typically done at a hospital .

I don't have any experience with Hospital infusions labs since my son always got his remicade infusion at his GIs IV lab. It was really great since all the kids there were getting infusions for the same thing he was. Plus the nurses catered to them with DVDs, snacks, blankets, Xbox live. Our GI is over two hours from us so it was a drive but we had the benefit of GI visits, lab work and inusions rolled into one. GI groups office was across the street from Children's Hospital so that was good too.

We did check into the price of having it done at our local hospital IV lab, since it was closer and son was in high school (9th-11th grade was remicade) and it was much higher. We weren't comfortable having it done there anyway so we were happy with the situation. I do know our insurance would've paid for it at local hospital since the GI lab was so far but this was before insurance companies started buckling down on it.

I dread this. My husband's hospital also charges the insurance company A LOT for this. Remicade by itself, is pretty ok. I hope you get some clarity and wish the insurance companies can freaking understand.

From my understanding many insurance companies are trying to keep infusions out of the hospital setting because of the higher cost. I always had mine done at my go docs infusion center and I really liked the infusion nurses there because of their knowledge and the relaxed atmosphere. Best of luck.

Here we don't have hospital based clinics for Remi. I've always done outpatient and fell very comfortable. The nurses have anaphylaxis meds and authorization to use then at their discretion (doctors standing order) and I am about 7 min away from a hospital. And realistically the rate of anaphylaxis is very low. Obviously a possibility but low.

My daughter had her infusions done at the local children's hospital until she turned 13, and then our insurance required us to move to an infusion center. It turns out that we like the infusion center a lot more; the nurses are better, and the infusions take less time (about 3.5 hours, vs 5 hours).

Our infusion center is open on weekends, but last year they changed the policy so that kids have to come on weekdays (because there are not pediatricians in the building on the weekend). So scheduling is more of a hassle now. Luckily, this year my daughter has PE at the end of the day, so I've been scheduling infusions from 2:30-6:00, and she just misses PE. Can your son change his schedule so that he has less important classes at the end of the day? I guess that doesn't necessarily help if you have a really long drive to the infusion center, though. How long is the drive?

Good luck. Hope you can find something that's not too disruptive.

Not sure if it's a Canadian or Ontario policy but we've never had our infusions done at the hospital; always an outside IV centre. They are a 'chain' of centres and we've found it to be very convenient. Because they are a 'chain', we have had the ability to move my son's infusion from one centre to another (ie near home vs near school, approx. 2 hours away) to accommodate exam schedules or unusual commitments.

Is it possible for you to access more than one location, perhaps one with a more convenient schedule? The 'chain' of infusion centres we use is called Inviva, they are owned by an American company - so, perhaps, they would be accessible to you??

As we've never had any choice, I haven't considered any greater risk??? But, regulations do state that a doctor must be on the premises. Although most of the centres that I'm aware of are stand-alone centres, my own family doctor's medical centre rents one room out for remicade (and other?) infusions.

Wondering, does anyone know the breakdown of the cost of remicade itself and the administration cost?

Tesscorm said:

Wondering, does anyone know the breakdown of the cost of remicade itself and the administration cost?

Click to expand...

From what I've seen on these forums, costs vary really widely from place to place, but here's what our bills have said:

At the children's hospital:
200 mg of Remicade: $4,752
Administration cost: $800
Lab fees: $270

At the infusion center:
350 mg of Remicade: $4,230
Administration cost: $234
Lab fees: $117

We have insurance through Kaiser, which is a big HMO, so the infusion center is a Kaiser clinic. The children's hospital is not a Kaiser hospital--Kaiser just contracts with them.

I'm not surprised that the administration fees are so much less at the Kaiser infusion center, but it's surprising that the Remicade itself is so much less expensive there too--about half the cost per milligram.

Tesscorm said:

Not sure if it's a Canadian or Ontario policy but we've never had our infusions done at the hospital; always an outside IV centre. They are a 'chain' of centres and we've found it to be very convenient. Because they are a 'chain', we have had the ability to move my son's infusion from one centre to another (ie near home vs near school, approx. 2 hours away) to accommodate exam schedules or unusual commitments.

Is it possible for you to access more than one location, perhaps one with a more convenient schedule? The 'chain' of infusion centres we use is called Inviva, they are owned by an American company - so, perhaps, they would be accessible to you

Click to expand...

I suspect it's a Canadian thing, I'm in Alberta and we have lots of different infusion companies and clinics. I don't think any hospitals here administer Remicade. I also love the flexibility in scheduling.

Thanks pdx. My son will only be covered on my insurance until next year, when he finishes school. I'm already starting to worry about what will happen then! If he finds a job that covers 100%, we're great. If not, then I don't know! I haven't looked into it very much yet but, from bits and pieces here, my understanding is that remicade assistance helps pay only for the drug... which is why I was wondering what was the breakdown.

I know it's maybe a bit early but I'm planning on calling our remicade coordinator in the next few weeks to see what advice/experience she's had with this.

Tesscorm said:

Thanks pdx. My son will only be covered on my insurance until next year, when he finishes school. I'm already starting to worry about what will happen then! If he finds a job that covers 100%, we're great. If not, then I don't know! I haven't looked into it very much yet but, from bits and pieces here, my understanding is that remicade assistance helps pay only for the drug... which is why I was wondering what was the breakdown.

I know it's maybe a bit early but I'm planning on calling our remicade coordinator in the next few weeks to see what advice/experience she's had with this.

Click to expand...

I think about this too, even though my daughter's only 14! I think it's a great idea to call your remicade coordinator--she will have seen many people's situations and I'm sure will have good advice. And yes, Remistart (the Remicade assistance program) helps pay only for the drug itself.

my little penguin said:

More and more insurance companies are pushing for outpatient infusions centers
Which are cheaper but not equipped to handle anaphylactic shock which can only be handled in a hospital .
Regardless of schedule
The risk of anaphylaxis is very high with remicade which is why it's typically done at a hospital .

Click to expand...

I don't agree with the above logic chain.

Outpatient infusion centers are very common for the administration of Remicade (among other things). Many private practice GI offices have one in house as a way to boost their revenue (under the guise of convenience to the patient).

Anaphylactic shock requires an epinephrine injection - the nurses at an outpatient infusion center can do this. All they do, all day, is administer infused medications - they know, and have standard operating procedures to deal with the major complications.

Of course, a severe reaction may require treatment by an MD, and they'll toss you in the back of an ambulance to get you to the nearest ER.

When I was on Remicade, my doctor was part of a big multi-specialty clinic / hospital organization. Thus, the infusions were done in the clinic attached to the hospital. However, when I was in college, they sent my orders to a small infusion center in my college town. It was fine. The nurse had the order, had the drug, and even had epinephrine ready to go in case of a reaction. She monitored my vitals regularly, just like the nurses in the hospital did.

A parallel is colonoscopies that are regularly performed in outpatient surgery centers. While these have much stricter licensing requirements than infusion centers ... if your GI perforates your colon, you're still going to need a ride in the back of an ambulance to the ER to get it repaired. Because they can't fix that problem on site, does that mean one should avoid all OSCs?