A: A lot of insurance plans these days are 80/20 plans, where the insurance pays 80 percent and you pay 20 percent. Let's say that you have rheumatoid arthritis and need Remicade treatments. They will cost you roughly $5,000 every six to eight weeks, so a 20% co-pay is $1,000. If you can't afford it, you can apply to one of two co-pay relief programs. One is through the Patient Advocate Foundation, the other is the Patient Access Network Foundation.
Q: How can I get an off-label treatment paid for by my insurance?
A: You may not be able to. There are drugs that have been used for off-label purposes for years and years and insurance companies don't balk at all. It's the newer very expensive drugs that are a problem. There is pending litigation against Medicare to try to get Medicare to pay for off-label uses. If that litigation is successful, it will change the landscape for commercial insurance as well. I actually never saw a denial of coverage of something that was off-label until Medicare had a drug benefit and they decided to deny coverage of off-label uses. So if Medicare is forced to reverse its position, you may be all set with your commercial insurance.
Share Your Thoughts
Have you had success or frustration getting treatment covered?
A: That should not be a problem. If you have an HMO, and you need a referral from your primary care physician, that's when things can get a little tight, because some HMOs provide incentives to primary care physicians not to refer to specialists. But in any other plan you ought to be able to go to a pain-management specialist. The key is finding one who accepts your insurance. A lot of top pain management specialists don't like to take insurance.
Your insurance company is required to maintain a provider directory that tells you every single doctor that is in network. If pain management is covered, and they don't have an in-network pain-management doctor in your geographic location, then you should be able to go out of network but not pay an out of network rate. If they can't provide you with a covered benefit in network, it's up to them to pay out of network.
Q: How do I make that happen?
A: Look to see who's in network, and if there isn't anybody, you go to your insurance company and say: "You don't have anybody in network for pain management. Is there anybody not listed in your provider directory?" They'll say: "Yeah, there are these ten doctors," and you'll call all of them, and they will say "We're not taking new patients," or "We don't take your insurance." So, go back to your insurance company, and say there is nobody in network, and ultimately the insurance company should cover it. If your insurance company won't cover it, and you're in desperate need, my advice is go to the doctor, and appeal the denied claim on the grounds that you tried every possible option in network. If you really get in trouble, that's when you call me.
