Crohn's Disease/ Remicade/ Aetna Question?

Question

Hi, was wondering if anyone could help me out. I recently moved to California from Japan to work at a travel agency. I am covered by Aetna Open Access Plan. I was diagnosed with Crohn's disease about 12 years ago and my specialist put me on a rigorous Remicade infusion plan because my disease was so severe. I was under the impression that Aetna would cover the Remicade treatments here but today I found out that I would be excluded due to the pre-existing condition clause. I have seen a few IBS/Gastroenterologist specialists in my area...they were the ones who told me I would not be covered (Aetna does not know about my condition). I am in need of Remicade as it has been the only drug on the market that has effectively had any impact on my health. Any advice for me? I would appreciate your help so much! Thank you.

Answer 1

Aetna does consider coverage of Remicade for Crohn's Disease to be medically necessary.  (Here's a link to Aetna's official policy on Remicaide:  http://www.aetna.com/cpb/medical/data/30... )

However, even though Aetna considers Remicade to be medically necessary, it may not be covered for you.

As another poster mentioned above, if you haven't had continuous health insurance in the United States, you have to go through a pre-existing conditions period.  This means that you won't have coverage for services related to conditions you had before your Aetna policy began...even if those services are medically necessary.  You would have to pay for the services out of your pocket, until your pre-existing waiting period was over.  Then Aetna would cover the Remicade, according to the benefits on your policy.

I know its probably hard to understand how pre-existing conditions work, since you aren't from the United States.  The one thing I would recommend to you is checking with Aetna to see if you can get the pre-existing conditions clause on your policy waived, by giving you credit for the health insurance coverage you had in Japan.

I used to work for a large health insurance company (not Aetna), and we had a case of a family who moved here from Israel.  Since they had  a national health plan in Israel, our company gave them credit for that coverage and didn't make the family go through a pre-existing waiting period.  (Because they had continuous insurance coverage...just not in the US.)

I can't guarantee that Aetna would waive the pre-existing period for you due to the insurance coverage you had in Japan, but its certainly worth asking about.  Remicade is incredibly expensive!

Good luck.

Answer 2

Contact the pharmaceutical company that manufactures Remicade. A lot of the time, they are willing to help if you meet their criteria, including income level and insurance status. Also, talk to Aetna about their policy about preexisting conditions; sometimes they will begin to cover medications after you have been enrolled with them for a certain period of time.

Answer 3

You're going to have to pay out of pocket.  OR, you can get on a group health plan through an employer, and wait out the pre-existing condition period, usually 12 - 18 months.  THEN they'll cover it after that wait.  

But that group plan will likely mean, you need to either switch jobs, or find a second job.