Facing a problem

Okay the twins started synagis shots in Nov; now with the new year they are no longer covered at 100% Granted I realize I was very blessed before to have an insurance plan cover these at 100% after the deductible (which they met while in the hospital last year) but now wieht the new year, they are only covered at 80% after the deductible. Okay I can understand the deductible part which would be $500 for both of them but if we continue the shots through April, we are looking at an additional $3000 out of pocket (our out of pocket maximum for each of them is $1500). So that's $3500 and that is a bunch of money. I just got one bill the other day for Luke's first hospital stay but haven't gotten anything on Jackson and Luke's second stay yet. So we still have that to pay off. I feel like such a bad mother; I mean I want them to have the shots but that is a lot of money right now out of our own pocket. Will people think I'm putting money above the health of my children? However here is the other side of this-the twins are currently not in a daycare, they are at home during the day with my sister in law watching them. She brings her 3yr old son but he is not around many children either. Everyone that handles the twins (which isn't many) has had flu shots and constantly wash their hands. We hardly if ever take them out because the pedi has warned us about having them out around a lot of people. The only places they really go is my parents house, my inlaws, and the doctor's office. As soon as they get back from the doctor's office, we change their clothes and wash their blankets. Also I work in a hospital and when I get home, before I even touch them, I change my clothes and wash my hands. So my question is this, what would you do? The twins case manager at our insurance company listened to my yesterday and said considering all the precautions we are already taking and with the new expense for the shots, she wouldn't continue with them. I asked about the insurance company grandfathering the twins in since we started the shots last year but they said no go. I really need advice on this one.

 

I elected to not do the Synagis last year with Alice and Royce (even though they qualified) because of the same exact reason. There is no way of being able to afford that much $ for a vaccination.

And you know what?

They didn't get sick. They didn't get sick with anything until a few months ago right before they turned 1. Then Royce caught a cold. And I took them everywhere with me. Grocery store, dinner, drug store, mall walking, outside walking, dog park, you name it they were there. And they were about the same gestational age and a little smaller than your guys. I'm not going to tell you yes or no, but when we were in that situation I said no.

 

QUOTE(becasquared @ Jan 13 2009, 07:17 AM) [snapback]1144785[/snapback]
I elected to not do the Synagis last year with Alice and Royce (even though they qualified) because of the same exact reason. There is no way of being able to afford that much $ for a vaccination.

And you know what?

They didn't get sick. They didn't get sick with anything until a few months ago right before they turned 1. Then Royce caught a cold. And I took them everywhere with me. Grocery store, dinner, drug store, mall walking, outside walking, dog park, you name it they were there. And they were about the same gestational age and a little smaller than your guys. I'm not going to tell you yes or no, but when we were in that situation I said no.



Thank you so much; I'm a first time mom and I'm freaking out about everything. They've already been congested twice and I feel like they've caught it from me since I'm out and about with so many people at work. I've been to the doc myself twice and gotten on meds to get rid of this crud.

QUOTE(becasquared @ Jan 13 2009, 07:17 AM) [snapback]1144785[/snapback]
I elected to not do the Synagis last year with Alice and Royce (even though they qualified) because of the same exact reason. There is no way of being able to afford that much $ for a vaccination.

And you know what?

They didn't get sick. They didn't get sick with anything until a few months ago right before they turned 1. Then Royce caught a cold. And I took them everywhere with me. Grocery store, dinner, drug store, mall walking, outside walking, dog park, you name it they were there. And they were about the same gestational age and a little smaller than your guys. I'm not going to tell you yes or no, but when we were in that situation I said no.



Thank you so much; I'm a first time mom and I'm freaking out about everything. They've already been congested twice and I feel like they've caught it from me since I'm out and about with so many people at work. I've been to the doc myself twice and gotten on meds to get rid of this crud.

 

When my LO's were that little last year, we did not have the RSV shot. They were basically around family at that time, we all washed our hands before handling them and were very careful about germs. They caught a couple of colds throughout the year but never RSV. I think you are doing a great job with the precautions you are taking and in no way are you a bad mother if you cannot continue with the shots. That's a lot of money to have to put out! I know I would not be able to afford it!

 

The pharmacy who sends my shots told me there is an assistance foundation that will help with the higher deductible. You can call your pharmacy and ask about it. I'm going to look in to it this week. I think everyone is in the same boat where we met our deductibles last year, but have to start over this year at a 20% co-pay, which stinks.

 

Talk to your pedi's office and see if they can call your insurance company on your behalf. :hug:

 

QUOTE(Leighann @ Jan 13 2009, 01:59 PM) [snapback]1144842[/snapback]
Talk to your pedi's office and see if they can call your insurance company on your behalf. :hug:


A great idea. For me, I would exhaust every avenue looking for assistance before I would just not get them the shot. I think they are very beneficial for premature babies.

 

We have had two shots already, have been extremely cautious (we go nowhere) and still caught RSV. Our hospital stay and repeated doctor's appointments are a lot more expensive than the shots would have been. Our insurance covers our shots, but the co-pays and hospital deductibles really add up.

 

The Patient Access Network Foundation might cover part of at least one of your shots. They covered some of Jo's shots when she was little. It looks like there is now an income requirement, but it's worth a try.

 

QUOTE(Jen620 @ Jan 13 2009, 10:35 AM) [snapback]1145104[/snapback]
The Patient Access Network Foundation might cover part of at least one of your shots. They covered some of Jo's shots when she was little. It looks like there is now an income requirement, but it's worth a try.


Thanks so much for all the advice; the insurance company won't budge on coverage even from the doctor calling.

 

QUOTE(JLF518 @ Jan 13 2009, 06:16 PM) [snapback]1145859[/snapback]
Thanks so much for all the advice; the insurance company won't budge on coverage even from the doctor calling.


Oh alsoI looked up the foundation website and we make too much to qualify now since their is now an income requirement.

 

OMG we are going threw the same exact thing....Twins got there shots Nov and Dec after fighting with the insurance company and 2 appeals later...my DH is fighting it still he understands the whole deductable but he thinks the shots should be paid for in Nov for 5 months...we are in an appeal.....now...as I dont know what we are going to do to pay that money I think ours is $600 each kid..... (my son had a real bad cold now< I am so worried)





QUOTE(JLF518 @ Jan 13 2009, 08:18 PM) [snapback]1145860[/snapback]
Oh alsoI looked up the foundation website and we make too much to qualify now since their is now an income requirement.

 

QUOTE(Brownie110 @ Jan 13 2009, 07:07 PM) [snapback]1145918[/snapback]
OMG we are going threw the same exact thing....Twins got there shots Nov and Dec after fighting with the insurance company and 2 appeals later...my DH is fighting it still he understands the whole deductable but he thinks the shots should be paid for in Nov for 5 months...we are in an appeal.....now...as I dont know what we are going to do to pay that money I think ours is $600 each kid..... (my son had a real bad cold now< I am so worried)


You know this just stinks. I mean I understand the whole deductible for the new year but my gosh they started the shots last year and I think they should be at least grandfathered in since they started these last year. This is insane! Its like okay get RSV, we'll cover your hospital stay but they won't cover the shots which help them for not going in the hospital. You know I found this out Monday and they are scheduled for their 4month checkup and the synagis shots Friday. I still feel bad because I feel like I'm putting money over there health but we just can't do this.

 

Wow! My twins who were born at 33 weeks and spent 3 weeks in the NICU did not even qualify for syntagis (sp?), because we did not smoke, and they did not go to day care. I was soo mad about this, and my pedi appealed their decision. We still have not heard anything. My babies have not got anything (knock on wood). I would file an appeal, talk to your insurance company, talk to your pedi, and if there is nothing you can do, than there is nothing you can do. You shouldn't feel like a bad mother.

 

My twins are due this week.....I understand how you feel......My dh has been talking to all supervisors even went to the company in person....and still nothing....My DH asked the company if they cover wood or plastic (coffin)cause that could happen if they get RSV....a little extreme but its the truth I am so worried that my sons cold (2 weeks) will develop RSV
Like you we cant afford $600 for each thats why we fault so hard to get the shot approved last year cause we couldnt afford it.....the company where the shot is coming from says they offer payments ..WHoopee Im not sure also if you can suddenly stop the shots...THis just stinks....Im so worried

My twins were born at 30 weeks spent 5 weeks in NICU .....




QUOTE(Melissatwins84 @ Jan 13 2009, 11:07 PM) [snapback]1146102[/snapback]
Wow! My twins who were born at 33 weeks and spent 3 weeks in the NICU did not even qualify for syntagis (sp?), because we did not smoke, and they did not go to day care. I was soo mad about this, and my pedi appealed their decision. We still have not heard anything. My babies have not got anything (knock on wood). I would file an appeal, talk to your insurance company, talk to your pedi, and if there is nothing you can do, than there is nothing you can do. You shouldn't feel like a bad mother.

 

Okay this has really been bugging me all week so I called the twins case manager at the insurance company again yesterday to see again if there was anything else we could do. She told me that after she talked to me on the phone, she and another coworker reviewed my plan and other claims from others-last year we should never have been covered at 100%. It should have been covered at 80%. All I know to do is to continue to be extra cautious and continue on with what we have been doing. They boys do go to the doc tomorrow for their 4mth checkup and wouldn't you know it is supposed to one of the coldest mornings tomorrow.

 

Insurance companies are so unreal....Im not sure what we are going to do...I know we cant afford it......I dont know what else we can do....Let us know how your checkup went





QUOTE(JLF518 @ Jan 15 2009, 08:50 AM) [snapback]1148045[/snapback]
Okay this has really been bugging me all week so I called the twins case manager at the insurance company again yesterday to see again if there was anything else we could do. She told me that after she talked to me on the phone, she and another coworker reviewed my plan and other claims from others-last year we should never have been covered at 100%. It should have been covered at 80%. All I know to do is to continue to be extra cautious and continue on with what we have been doing. They boys do go to the doc tomorrow for their 4mth checkup and wouldn't you know it is supposed to one of the coldest mornings tomorrow.

 

QUOTE(Brownie110 @ Jan 15 2009, 01:56 PM) [snapback]1148701[/snapback]
Insurance companies are so unreal....Im not sure what we are going to do...I know we cant afford it......I dont know what else we can do....Let us know how your checkup went



I will let you all know how tomorrow goes. Also, wouldn't you know it that tomorrow is going to be the coldest morning too her in Arkansas? We are looking at single digits in the morning and the boys have to be at the doctor at 8:30! I keep thinking, okay what are the warmest outfits? I know the time outside is brief but still considering they won't be getting these shots anymore, thsi bothers me! Am I totally freaking out over nothing?

 

No not at all.....I would be freaking out to.....Its cold here in Philadelphia to ....Im going crazy sitting in the house...but I dont want to take the babies out if I dont have to.. Good Luck tomorrow and bundle up bbrrrrrr





QUOTE(JLF518 @ Jan 15 2009, 08:04 PM) [snapback]1149016[/snapback]
I will let you all know how tomorrow goes. Also, wouldn't you know it that tomorrow is going to be the coldest morning too her in Arkansas? We are looking at single digits in the morning and the boys have to be at the doctor at 8:30! I keep thinking, okay what are the warmest outfits? I know the time outside is brief but still considering they won't be getting these shots anymore, thsi bothers me! Am I totally freaking out over nothing?

 

OMG...check out the new stats for my boys below; today they had their 4mth checkup. Jackson is HUGE!!!

 

WOW! :ibiggrin:

My boys are 20lbs at 1-year!

 

WOW....big boy,,,, mine are 19lbs almost 20 at 9 months






QUOTE(mama23boys @ Jan 16 2009, 11:53 PM) [snapback]1150691[/snapback]
WOW! :ibiggrin:

My boys are 20lbs at 1-year!

 

My girls qualified the first year. Jilly was hospitalized 3 times but it wasn't RSV any of those times. They didn't qualify in winter number 2. Both got RSV at 19 months - it was HORRIBLE. Anna was in the hospital for 4 days and Jilly probably should have been. The bill for Anna was a lot along with the ambulance ride etc. Insurance co's really gamble with our kids health. Grrrrr.

 

QUOTE(Corinne923 @ Jan 17 2009, 10:25 PM) [snapback]1151557[/snapback]
My girls qualified the first year. Jilly was hospitalized 3 times but it wasn't RSV any of those times. They didn't qualify in winter number 2. Both got RSV at 19 months - it was HORRIBLE. Anna was in the hospital for 4 days and Jilly probably should have been. The bill for Anna was a lot along with the ambulance ride etc. Insurance co's really gamble with our kids health. Grrrrr.


I agree they really do gamble with our kids health, it really is insane. There were 5 babies in the hospital when I left work Friday with RSV.

 

I didn't read all of the replies, so I don't know if this was said already, but I didn't get the synagis shots with DS (who was born early and weighed only 5 pounds)...the research I found was that it only actually lowers the risk of getting RSV to 50%...and with the sheer cost of the shots and the fact that frankly, they haven't been out on the market all THAT long...I didn't think it was worth it for only a 50% reduction. He never did get RSV. It's a personal decision. Good luck!