Reclast covered by insurance

I had my first reclast infusion on 2/5- after I was assured by the infusion center that it was covered by my new Aetna Medicare Open plan.
I just got my explanation of benefits from Aetna- they have denied the entire claim ($2044 for the Reclast and $235 for the infusion) because it was "experimental". They say that since i did not agree in writing to pay whatever they denied prior to the infusion that I am not responsible for anything.
I was a little surprised to read that they consider this to be experimental. Just in case anyone else is looking at getting this make sure you check with your insurance company first.
By the way- after having very bad 'flu like" symptoms on days 2 & 3 I have not had any other side effects from the infusion.

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First of all, if Aetna is charging you $2044 just for the Reclast they may be ripping you off because Blue Cross/ Blue Shield charged me $1250 (of which they paid 80% and I paid $250). The the hospital charged a couple of hundred to do the infusion, I forget exactly although the BC/BS "explanation of benefits" came last week; they had covered the entire amount of giving the infusion so I just checked it. As for Aetna categorizing Reclast as an experimental drug I would definitely challenge that as Reclast was approved for osteoporosis treatment last August by the FDA. I can't speak about Aetna's pre-approval policies but I am absolutely certain of the drug's approval date.---just now I double-checked on google and it was August 17, 2007. Some clerk may be working from an old list or Aetna may just be dragging its feet since the drug is expensive. I did call BC/BS beforehand to make sure they were going to cover since I figured Reclast would be expensive (although I believe the cost isn't more than a whole year of Fosamax, and you might point that out to Aetna---check the exact cost of Fosamax at your local pharmacy so you can speak with authority). You give Aetna H-E-Double Toothpicks---an approved drug shouldn't be an "experimental" drug. Sometimes we have to go through life educating the public. If Aetna continues to give you grief about this, notify the MD who prescribed it and suggest that he tell the pharmaceutical rep he works with (I can't find a Novartis customer service phone # for the US---company seems to be based somewhere else). Definitely the company will want to know if an insurance company is doubling the price and refusing coverage.

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The charges were probably from the infusion center not the insurance company. Insurance companies usually have an appeals process (if Aetna did not include a copy with your EOB contact them for instructions). The infusion center may file an appeal but you will want to be sure that the insurance company will pay for future infusions. Part of your appeal certainly should include the FDA approval.

Good luck and let us know how it all turns out.

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I just realized you said your insurance is Aetna Medicare Open; I'm on Medicare with a supplement policy from Aetna but my doctors, labs, etc. all have to be filed with Medicare first. I don't know if your Aetna policy works that way (they all seem to be different).

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Thought I would give you an update on my insurance problem- after a week and a half on the phone with everyone at Aetna I finally found out- someone slipped in telling me- that my doctor's billing dept had coded it wrong- they were coding it with my arthritis code instead of the osteoporosis code. When I then called my doctors office with this information they said it was in review- I told them I could save them a lot of time they just needed to recode it.
Anyway- Reclast is covered for osteoporosis...

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A PS to this discussion of Reclast and insurance: in the past two weeks I have seen two full-page ads for Reclast in the New York Times and several ads for it on television so I guess we Reclast people can now come out of the shadows and be mainstream.

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I have been checking with my insurance Co.(UHC)
before I am to have the Reclast done some time next week. They said that they do cover all of the cost of the procedure. That is really good news for me. I am glad to hear that Aetna covered the cost for you. I think most insurance companys gives you a hard just for the fun of it. They make you work for it!

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I first started reading your discussions as I was scheduled for a Reclast treatment on 4/14. I asked my doctors office if it was covered and they said yes CIGNA indicated to them that they would cover it after my deductible was met. I am 60 years old and work fulltime and have a high ($2250) annual deductible with an HSA. I asked the doctor's office what the cost of the treatment was and they didn't know. I called the hospital billing department and they never heard of Reclast and had to get back to me. When she finally called she asked if I was sitting down. The cost here in Vermont is $3,798.39 I was hesitant anyway due to the side effect of Atrial Fibrillation (which none of you has talked about) and after that price quote, I canceled my appointment.

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My doctor's office still has not corrected the diagnosis code error they made initially. Since they are the ones getting the money and they do not seem worried I am not either. Once they resubmit with the osteoporosis coding they will be paid all but my $25 copay.
The only symptoms I had were the second & third day- fever, chills, headache and unbelievable fatigue...absolutely nothing since. My only concern is that I have trouble remembering the evening calcium pill and I think you need to have the calcium to help the Reclast.

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I am 74 years old. I have Medicare and a supplemental insurance. I had bone density test in April of this year and the results were that I had osteoporosis. My doctor prescribed Evista. Even with my Plan D prescription plan the that is taken everyday is very expensive. My friend told me about Reclast infusion she had. She told me Medicare paid the cost. I made an appointment got a Reclast infusion. Before I even got in to see a doctor, the nurse told me I did not qualify for Medicare to pay the cost. She told me I would have to prove that I had taken three different medications with no improvement in order to qualify.
Has anyone run up against this problem?

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No, I have had 2 doses of the Reclast and have not been charged anything other than $25 co-pay last year (2/08 & 4/09)
I have Medicare with Aetna as additional - this year I have no deductibles or co-pays as it is an Aetna Intergration Plan.

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My insurance plan, Medicare, denied coverage for Reclast. My oncologist appealed the denial twice but it didn't help. The reason for the denial is that I have to have osteoperosis in order for it to be covered. My doctor pointed out that she wanted me to have the injection because I have osteopenia, which is usually a precursor to osteoperosis. (I had chemotherapy a few years ago and that often causes bone loss.)

Unfortunately, the clerks at insurance companies don't have decision-making authority and their superiors' job is to save the company money, so it's a losing battle.

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I had a reclast infustion in september. Medicare and Blue Cross paid every thing. It didn't cost me anything.

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