Insurance coverage, round 1

I say “round 1” because after everything I’ve read, this is going to be a long process to get Hannah covered and to find out exactly what Aetna will end up covering.

Apparently it isn’t as straight forward as 90%/10% (we cover 10%) and a yearly max-out-of-pocket like our coverage says. Basically, Aetna, our doctor’s hospital group, and Genzyme (who make the cerezyme) are going to “negotiate” a payment, and then it has to go to the Aetna review board for approval. I would love to be a fly on that wall! It is my understanding that once the review board goes through and comes up with what Aetna will pay and what we are responsible for, then I’ll hear back. Many people I’ve talked to said that they have had to appeal the decision, some with favorable outcomes and some with no change.

The only positive so far is that Aetna already has active codes for the ERT (enzyme replacement therapy) and the process for it, so Hannah won’t have to go through a precertification process before getting started. It should save us some time.

I’m hoping to hear back from our Genzyme rep who is working with Aetna and our doctors. Thank goodness for her… she at least is getting us answers and a lot faster than I could!