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Feel like a broken record - Fragile x and SMA related
Hi ladies,
Thanks for all the support on my other thread about certain tests not being covered by my insurance. I'm trying my hardest to figure out OOP costs.
So, genetic testing to see if I'm a carrier of fragile x and SMA are not covered by my insurance without pre-authorization, which my dr. won't give. Did anyone face a similar thing? Did you go through with the testing anyway and pay OOP? Did you decide to forego those tests? TIA
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Posted 9/24/14 4:32 PM  |
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jessnbrian
Only God knows His plan for us
Member since 4/13 7238 total posts
Name:
Jessica
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Feel like a broken record - Fragile x and SMA related
I think that some of my bw wasn't "covered" but it was processed as OON, so it would depend on what your OON benefits are like. I hope this helps! I would also shop around to find out who could do this for you the cheapest (each lab sets their own prices).
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| Posted 9/24/14 4:53 PM |
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Re: Feel like a broken record - Fragile x and SMA related
Thanks, Jess. I will check my prescription when I get home, but my dr is through LIJ (yours it too, no?) and they gave me a list of locations I could go to for the blood draw. it doesn't even say what lab they send out too.
ETA - is this something I even have to really worry about since I'm 34?
Message edited 9/24/2014 5:13:44 PM.
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| Posted 9/24/14 4:58 PM |
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jessnbrian
Only God knows His plan for us
Member since 4/13 7238 total posts
Name:
Jessica
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Feel like a broken record - Fragile x and SMA related
Yup! I can tell you that so far for ALL of the "non-covered" bloodwork from week 6 through today (week 29 & 1/2) the total OOP for me has been $200, so it's not insane (this is through the LIJ labs) .... BUT, like I said on a previous post, I was NEVER informed that these tests would be OON for me, so I am not paying so far and forcing the office to look into it.
I'll also add, that LIJ is VERY good about waiving or reducing out of pocket costs, I had a very good experience with them a number of years ago when my DH was in the hospital twice in one day (don't ask, MRSA related, he's had it 3 times so far) and we got massive bills because he had issues with his cobra - $5K in bills down to a total of $500 (maybe less).
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| Posted 9/24/14 5:16 PM |
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Lillies
Grateful for my babies!
Member since 2/12 4571 total posts
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<3
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Re: Feel like a broken record - Fragile x and SMA related
I wonder why there is such an issue. I had both tested as part of my genetic screening and it was covered no issues. Maybe bc it was through a Reproductive Endocrinologist?
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| Posted 9/24/14 5:20 PM |
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Re: Feel like a broken record - Fragile x and SMA related
That's good to know!
I guess I will call and ask if they can send it to a quest lab since that is in network for me. I'll also ask them if they can give me the cost for those two tests, if I pay OOP.
The lab they use for the NT scan bloodwork is OON for me (NDT or something like that) and they've offered to also send me to Quest for that. I was worried it might affect the test somehow, but I don't see how it could. They are just taking blood the day after the measuring sonogram and sending results to the dr, right?
Sorry to hear about your husband, BTW! That sounds awful, I hope he is ok now.
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| Posted 9/24/14 5:22 PM |
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Re: Feel like a broken record - Fragile x and SMA related
Posted by Lillies
I wonder why there is such an issue. I had both tested as part of my genetic screening and it was covered no issues. Maybe bc it was through a Reproductive Endocrinologist?
The reps at Cigna I've spoken to say they are "sophisticated tests" and they aren't "required" but are optional. Since they're optional, my dr. won't send a pre-authorization for them. I just don't know how worried or not I should be about this.
Is there somewhere else along the way that they would pick up if there were an issue? Another test or sonogram that might catch it?
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| Posted 9/24/14 5:23 PM |
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jessnbrian
Only God knows His plan for us
Member since 4/13 7238 total posts
Name:
Jessica
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Feel like a broken record - Fragile x and SMA related
I only got my bill about 2 months later... so keep any eye out... But, Lillies, you have INSANELY GOOD COVERAGE!!!!!!!!!!!!!!!!!!!!!!!!!! Mine's good, but yours is incredible.
I think it is just for the bw, and yes, I think that one set of bw wasn't done through LIJ. It really hasn't come to that much (in the long run), and for me Quest is OON too.
Thanks! Yeah, he's fine now, just something we have to keep an eye out for, it's apparently one of those things where once you have it you are prone to getting it. And let me tell you, those things SMELL so bad, worst infection smell ever... and I worked in wound care!
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| Posted 9/24/14 5:26 PM |
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Lillies
Grateful for my babies!
Member since 2/12 4571 total posts
Name:
<3
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Re: Feel like a broken record - Fragile x and SMA related
Posted by TryingandHiding
Posted by Lillies
I wonder why there is such an issue. I had both tested as part of my genetic screening and it was covered no issues. Maybe bc it was through a Reproductive Endocrinologist?
The reps at Cigna I've spoken to say they are "sophisticated tests" and they aren't "required" but are optional. Since they're optional, my dr. won't send a pre-authorization for them. I just don't know how worried or not I should be about this.
Is there somewhere else along the way that they would pick up if there were an issue? Another test or sonogram that might catch it?
That makes sense. The reproductive Drs deem all of these tests necessary and part of protocol so they may have preauthorized. Look, it's genetic screening so unless you are aware of people in your family with SMA or FragileX, then it's probably not necessary. My OB requested the same tests from me when I first met him and was happy I had them done already. I think many OBs are now adding these to their new patient protocol but it may not be completely necessary- just more info is always better. Same for the panorama. It's only truly necessary with women over 35 or with a history of downs or if NT scan comes out abnormal but other than that, you don't really need it. It's access to information which Drs love and who wouldn't love to know if they are having a healthy baby by 10 weeks? I wish I could have had it but it was not deemed necessary by GHI and I decided to just wait out the NT scan and anatomy scan.
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| Posted 9/24/14 5:56 PM |
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pumpkinmom
LIF Adult
Member since 5/12 2911 total posts
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Re: Feel like a broken record - Fragile x and SMA related
I'm so sorry you have to do all this legwork to get your blood tests.
I don't recall if I had those genetic tests. I didn't get anything extra- just the standard tests my ob gives everyone.
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| Posted 9/24/14 6:13 PM |
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Re: Feel like a broken record - Fragile x and SMA related
Thanks ladies.
Lillies- it makes sense to me too that the insurance company doesn't cover it, but I'm not used to making decisions about my healthcare like this. Before pg, if I saw a dr and they ordered a test, I would get it done. I've never had to turn something down bc of insurance or make a decision contrary to a drs recommendation, so this is all new to me.
I'm trying to stay positive that if it were necessary insurance would cover it, but it's also hard to imagine that an insurance company really has my best interest in mind.
I'm going to try and call LIJ today to see if they can tell me how much those two tests would cost oop.
Thanks for all the support!
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| Posted 9/25/14 8:45 AM |
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LuckySV
LIF Adult
Member since 10/05 4675 total posts
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Re: Feel like a broken record - Fragile x and SMA related
Why won't your doc get preauthorization for you? That makes no sense to me! Although, it doesn't make any sense why these tests are covered. I thought they were pretty basic tests for pregnancy.
Maybe you should contact your insurance again and speak with someone in management.
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| Posted 9/25/14 11:34 AM |
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Lillies
Grateful for my babies!
Member since 2/12 4571 total posts
Name:
<3
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Re: Feel like a broken record - Fragile x and SMA related
I think it's more your Drs fault putting you in this position. Drs should only put you through testing that is necessary for treatment. When they start prescribing unnecessary things, it puts you and the insurance companies in awkward positions. Drs are allowed to recommend any tests they like for their practice but at least sit with you and explain all tests and their priority levels instead of freaking you out.
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| Posted 9/25/14 11:47 AM |
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LovesMike
LIF Adult
Member since 8/10 978 total posts
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Re: Feel like a broken record - Fragile x and SMA related
LuckySV - the dr. won't send a pre-authorization through because its an optional test. It's recommended, but not required.
Lillies - I agree with you again. Makes me suspicious of doctors in general.
I spoke with a very nice woman at LIJ today and she gave me the price for those two blood tests is $2K. She said to get them done and then give her a call back (I got her direct number) and they'll offer me a generous reduction, which is customary I guess. It will still be a few hundred dollars, but at least not $2K.
Now we need to decide if we are going to go through with it or not. Too many decisions already!
ETA - I also just gave away my real "identity" whatever. I'm also TryingandHiding! I'm out! I don't think anyone IRL is really lurking on here anyway. But I'm still not out IRL . . . 
Message edited 9/25/2014 11:59:27 AM.
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| Posted 9/25/14 11:58 AM |
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Michelle1110
My family is complete
Member since 1/12 2338 total posts
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Re: Feel like a broken record - Fragile x and SMA related
Posted by Lillies
I wonder why there is such an issue. I had both tested as part of my genetic screening and it was covered no issues. Maybe bc it was through a Reproductive Endocrinologist?
This. I was billed $100 for me and $100 for DH. I signed paperwork saying I was only responsible for $100 from my RE, regardless of my insurance.
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| Posted 9/25/14 12:30 PM |
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