Same Drug, Same Procedure, Different Cost

Last updated: May 2018

My primary RA medication is a biologic that I get via infusion every four weeks. Normally I get the treatment in a dedicated infusion room at my doctor’s office. There are things I like and things I don’t like about this arrangement, but the point of this article is that I only have a $50 copay, just like a regular specialist office visit. My insurance pays the rest.

My rheumatologist is the only doctor in her practice and she is going on vacation. This is great for her, but my next-scheduled infusion is during the time that she will be gone. This causes a problem because for a number of reasons the infusion can’t be done during her absence.

They checked with the insurance company about doing the infusion a few days early while she was still in the office and the insurance company won’t cover it. This is similar to trying to refill your prescription too early. I could still do that, but I would be liable for the approximately $10,000 for the drug and administration costs. That’s not an option.

I could wait until she gets back, but then I would be two weeks late getting the medication which would put me in a major flare. That’s not a good option, either.

The answer is my rheumatologist is part of the medical complex associated with a major hospital and we have scheduled my treatment at the infusion center at the hospital. I will get it on the correct day and insurance will therefore cover it.

But it will cost me $170 instead of $50.

Same drug, same procedure, more than three times the cost to me.

The reason is insurance companies have different rules for covering drugs depending on whether you get them from a pharmacy and administer them yourself, whether you receive them at a doctor’s office, or whether they’re administered in a hospital or similar health facility.

Since I’m getting the infusion at the hospital, the procedure and drugs are being covered as if I were a hospital patient. It doesn’t matter that it’s the same drug. It doesn’t matter that it’s the same infusion procedure. The setting affects the coverage.

It’s important to understand these differences if you have a choice in drug treatment. If your doctor gives you an option of infusion centers – hospital-based, independent, in-office, etc. I would highly recommend you speak to your insurance company to find out how they cover each facility. Based on your policy it might not make any difference, or it could mean hundreds or even thousands of dollars out of pocket.

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This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

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