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Same Drug, Same Procedure, Different Cost

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.

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.


  • Carla Kienast author
    3 years ago

    As an update to this post, when I got the bill from the hospital, it wasn’t $170. It was $543 — more than triple the estimate and more than 10 times what I would have paid if I had waited and had the infusion at my doctor’s office. I have protested but I have no hope of getting an adjustment on this charge.

  • Deedl
    3 years ago

    Is there any chance of getting a home infusion? Not sure if the cost would be less than at hospital but it’s a different avenue to explore.

  • Carla Kienast author
    3 years ago

    Hi. What an excellent question. I apologize for the late answer. The issue, as I understand it, is that there needs to be a doctor nearby/on call in case of a reaction to the drug, so a home infusion doesn’t sound like an option. However, I have talked to my rheumatologist about this situation and there may be a possibility for a different infusion center and/or doctor’s office.

  • cateepoo88
    3 years ago

    My husband is starting a new job in a few weeks. I’m really nervous about what and how things will be paid. The system is crazy.

  • Lauren Tucker moderator
    3 years ago


    Best of luck to your husband and we understand that it can be scary not knowing how things will be paid. In the meantime, I thought this article might be helpful to you:

    We wish you and your husband all the best and we are glad to have you in our community.

    Best Wishes,
    (Community Manager

  • Carla Kienast author
    3 years ago

    As well as learning all the new rules, another one of the tough parts of changing jobs/insurance companies is starting all over with deductibles. Fingers crossed it will be good coverage for you guys.

  • Brenda Gordon
    3 years ago

    This is what makes healthcare so complicated. I am astonished by how much I have to manage, self-educate, and constantly follow up on the cost of my care and office visits. I do it but it is a lot to manage on top of a full time job. It can be stressful, also.

  • Carla Kienast author
    3 years ago

    I agree, Brenda. It often feels like having a chronic disease is a full-time job in itself. Not only do you have to manage your health, you have to manage your healthcare and the associated costs. Thanks for your comment. Your words resound with many of us.

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