High-Risk Pregnancy

Progesterone Shots-problems with insurance

So, I had a cerclage stitch put in last week and had a progesterone shot in the hospital (which sucked) and I am supposed to get them weekly till the baby comes.  My husband picked up a Rx for me and the pharmacist said there was an Rx for 8,000.00.  It was the shot.  We assumed there was some kind of mistake because for one, I didn't think I would get it from the pharmacy and ins. didn't pick up any of the shot.

Long story short....I will be getting it from the pharmacy (mail order) and it is NOT covered under insurance.  Yet, it's medically necessary.  Has anyone had any problems getting this covered?  I'm going to be so pissed if the insurance still says it's not medically necessary.

Re: Progesterone Shots-problems with insurance

  • Mine was not covered under the perscription coverage of my policy, but was covered under the medical part of my coverage.  Not sure if that helps you, I didn't have to do anything special, but it is worth calling your insurance and asking.
    BFP#1 4/8/2012 DD born at 35 weeks on 11/10/12
    BFP#2 11/13, Ectopic diagnosed 12/6/13, Tube and Ectopic Removal 12/16/13 
    BFP#3 3/14, Natural M/C 3/18/14 
    BFP#4 4/18/14, heard heart beat (164) 5/14/14, EDD 12/25/14

      image

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  • abenson3 said:
    Mine was not covered under the perscription coverage of my policy, but was covered under the medical part of my coverage.  Not sure if that helps you, I didn't have to do anything special, but it is worth calling your insurance and asking.

    thank you so much!!!


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  • Talk to your doctor and have his admin speak to your insurance. Mine was denied initially as well, but after it was resubmitted with additional explanation/info from the doc it went through. Now i pay $59 for 5 shots. Not bad.
    BabyFetus Ticker
    nikkitaplin
  • acutypie said:
    Talk to your doctor and have his admin speak to your insurance. Mine was denied initially as well, but after it was resubmitted with additional explanation/info from the doc it went through. Now i pay $59 for 5 shots. Not bad.
    thank you.  still waiting to hear.  I have an apt tomorrow.  I'm going to talk to the doctor.  I also saw on Makena's website that they offer assistance.  I am going to print that info off too.
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  • AnonnAniAnonnAni member
    1000 Comments 500 Love Its Fourth Anniversary 5 Answers
    edited July 2014
    @nikkitaplin‌ I am on the shots and I had the WORST time getting them from the RX company but they they should be covered for you. If you have cerclage and you insurance convered that procedure then in your chart it lists you as subject to pre-term labor to some extent so they should be able to do a review if you Dr resubmits the info...
    They may need it stated in a certain manner to be covered. I went through 4 weeks of getting all my ducks in a row and ended up starting my shots late over the craziness. I had to call every two days for 4 weeks and talk to a different person each time to find out what more was needed etc.
    And even offered to pay for the vial out of pocket and wait to be reimbursed so yeah that $8,000 is right sadly.
    BUT that should be covered under your insurance!
    If it is not then you also said your hospital gave you the shot which means they are considered a "dispensary" for it. See if the office can arrange to bill your insurance for it and you have to endure going in weekly for it. BUT the first shot they gave you is obviously going to be billed to your insurance so that is one way around it if you cant get the RX itself covered...
    I did that at my last hospital some shots I got there b/c they were graded as a "dispensary" of compounds but now that I go to the hospital where I work we are not so I had no choice but to go through insurance soley.
    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
    Baby #1 7/16/10
    Baby #2 11/14/12
    Baby #3 12/11/14
    Baby #4 Due 3/26/17
    Naturally with PCOS


  • AnonnAni said:
    @nikkitaplin‌ I am on the shots and I had the WORST time getting them from the RX company but they they should be covered for you. If you have cerclage and you insurance convered that procedure then in your chart it lists you as subject to pre-term labor to some extent so they should be able to do a review if you Dr resubmits the info...
    They may need it stated in a certain manner to be covered. I went through 4 weeks of getting all my ducks in a row and ended up starting my shots late over the craziness. I had to call every two days for 4 weeks and talk to a different person each time to find out what more was needed etc.
    And even offered to pay for the vial out of pocket and wait to be reimbursed so yeah that $8,000 is right sadly.
    BUT that should be covered under your insurance!
    If it is not then you also said your hospital gave you the shot which means they are considered a "dispensary" for it. See if the office can arrange to bill your insurance for it and you have to endure going in weekly for it. BUT the first shot they gave you is obviously going to be billed to your insurance so that is one way around it if you cant get the RX itself covered...
    I did that at my last hospital some shots I got there b/c they were graded as a "dispensary" of compounds but now that I go to the hospital where I work we are not so I had no choice but to go through insurance soley.
    Thank you!  I was on the phone yesterday for about an hour with the ins company trying to get this figured out.  FINALLY, today I got a call that it is covered at 100% as long as the meds are sent to the doctors office and its done in the doctors office.  It is only covered as a medical procedure not through the pharmacy portion of our ins.  Whew!  So they start aug. 5.  to dec. 23 unless I go into labor before then.  The one I got in the hospital burned SO bad.  Are they all like that? 
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  • Sadly you get kinda used to them :-(
    If they are sent to your Dr's office ask the office or you NP or OB directly can you have the vial and a few syringes to administer at home (also have them so you how to do it- though there is a youtube video that most offices point you in the direction of to view that was done by fertility village I think). They may give it to you and save you the trip each time. I do mine at home at night so I can sleep through any side effects I might have lol.
    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
    Baby #1 7/16/10
    Baby #2 11/14/12
    Baby #3 12/11/14
    Baby #4 Due 3/26/17
    Naturally with PCOS


  • @AnonnAni


    SIDE AFFECTS?!?!?!!  OH NO!!!!  I'm scared! LOL


    I'm one of those...lets just get it over with so they are every Tuesday at 8:30 am! LOL....This baby better love the crap out of me for having to do all this! LOL (only kidding...he/she better love me for my awesome personality..lol)

    I'll ask about doing it at home.  Copay is $30 each time but I figured if the nurse did it then there is no copay but the insurance said yes it does.  We originally thought we would have to pay upwards of $400 a month so $30 a week is much better!

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  • $30 a week is way better BUT that $30 is also a box a diapers you could be stocking up on a week as well lol so never hurts to ask can you have your vial lol. And yes there can be side effects and sitting will be sore and once you int he swing and have done both sides since you rotate the side after your well into it both sides are just sore lol *smh* mothers days presents need to be cars and boats etc lol
    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
    Baby #1 7/16/10
    Baby #2 11/14/12
    Baby #3 12/11/14
    Baby #4 Due 3/26/17
    Naturally with PCOS


    nikkitaplin
  • Def. ask if they can show your husband how to administer it. Its not that hard and it will save you on the copays which add up. Thats what i do and I just pick up the vial from the doc and the shots and supplies from them and let them know when i need a refill and they take care of the rest.

    Yes there are side effects unfortunately. The shots hurt, sometimes alot! but sometimes not so bad. Only reaction i have had is a bump forms so always switch butt cheeks and different locations as to not have too much scar tissue build up in one spot. (the needle is thick hence the scar tissue) I reacted worse than most people and at first my "bumps" spanned 6" across and were horrible colors. The doc said it was normal, i was just more sensitive than most. That lasted the first 3 weeks or so, it has since gone away which is good.
    BabyFetus Ticker
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  • I was told they will do it in my leg??  Is that not where most get it?  I'm assuming you are talking about the 'back side'.  lol


  • It goes in the hip area, upper outer area of the butt. Honestly, i wouldn't want it in my leg. the needle is pretty big since the medication is thick, so it takes a few seconds to go in. Hence the soreness afterwards.
    BabyFetus Ticker
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  • The leg for an 18 gauge 3inch needle I would lose my mind!!!!
    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
    Baby #1 7/16/10
    Baby #2 11/14/12
    Baby #3 12/11/14
    Baby #4 Due 3/26/17
    Naturally with PCOS


  • yeah they put it in my leg when I got my first one in the hospital after my cerclage.  I was in tears. It hurt so bad so that's why I'm freaking out!
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  • I paid $45 for a month's worth of shots (I do 2x a week). I got mine at a compounding pharmacy. The first one was administered by my doctor, but mostly to show my DH how to do it.

    I was told to go in the upper butt/lower back area. I get REALLY sore for several days after, but the actual shot doesn't hurt. The trick is to pull you skin while the dr/DH is administering the shot. I grab my fat at pull to the side, and DH sticks it in. He goes slow, releasing just a little bit at a time. It's oil, so it's thick and takes time to work into your body. He does a 1-2-3 count, and I release my grip on my skin as he pulls the needle out. It prevents the burning, I guess?

    Married 12.9.06

    DD born 1.6.11

    TTC #2 since 7.12

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  • takmjstakmjs member
    Seventh Anniversary 100 Comments 25 Love Its Photogenic
    We had a heck of a time getting our insurance to cover giving me the shots closer to home, bc it's 90 minutes to the hospital where I get my high-risk care normally. The nurse at the MFM's office did most of the work for me, and after 8 weeks, I can now finally get the shots done in the town where I work--30 minutes from home. The clinic close to me initially said they wouldn't administer them, bc I wasn't under their care, even though we were only asking them to give me the injection and my MFM would sign for the medicine. The nurse finally got an independent pharmacy to supply the medicine, who delivers it to my house themselves, then I take it to the clinic to get the shots. It's been quite a process, but I guess it's almost $5,000/vial for 5 weeks worth of injections, so my nurse said the first week that I'm getting $1,000 put in my butt every week. And yes, upper butt/hip area. I've only had one really painful shot, but I think that was more the nurse's technique. When she said "here's a pinch," I was expecting the shot. Instead, she pinched my butt to grab the area she was going to put the shot, and it scared the crap out of me and tensed me up big time. I've been a little itchy at the site just randomly throughout the weeks, not right after the shot. Good luck!
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  • takmjstakmjs member
    Seventh Anniversary 100 Comments 25 Love Its Photogenic
    Sorry for the 2nd post. I was also going to mention that my insurance was more willing to pay for the non-FDA-approved version of the progesterone, so if you have issues getting the makena covered, you may be able to switch to the other version of the medicine. The nurses said it's the same medicine; it just hasn't been FDA approved, and it's like $60 vs $5000.
  • I'm really nervous to get these done every week but I know it's worth it.


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