HER2 Support Group Forums - View Single Post - Pertuzumab not avaliable to stage 4 contrary to what you have heard

7andcounting · 07-06-2012, 08:40 PM

Hi Ladies,

This is what I am finding. If you have had Herceptin, then you do not qualify for Pertuzumab.

Your ins. company can tell you that you do not need pre-authorization for this drug, b/c IT IS an approved drug, but the FDA approved it in such a way that it is for stage 1 breast cancer. (I am stage 4)

You can even get a pre-determination letter. This means nothing, as I have found out. Your company will then send you a letter that says that the pre-determination letter is NOT a garuntee of payment.

1st dose is a loading dose. Cost:$22,000. Next doses are $11,000 every 3 weeks.

Until you get your EOB (Explanation of Benefits) back from your ins. co., WEEKS after that 1st infusion, and likely AFTER the 2nd infusion, and you see if your ins. has paid, you will not know if you are going to be stuck paying this yourself.

My Oncologist told me I had to sign a paper saying I was liable for this entire amount, if my ins. didn't pay this.

My oncologist said the insurance company may come in and after I have already had the infusion, and do what is called, "reto-deny."

Drs. give drugs off label all the time, but since this is so newly approved with the FDA it looks like those of us who need this are just plain stuck.

Really, I have ins., and I am supposed to sign a letter saying I garuntee to pay this huge bill if my ins. co. decides not to pay? There should be a way that we can be sure that the ins. company will pay----or not.

Is there anyone on these boards who works in the ins. industry that could help me? Do you know how I can get the insurance co. to garuntee payment?

I needed this drug yesterday! I have orders in at my onc's office to get this, but here I sit in limbo b/c I can not afford to gamble this huge amount of money ($33,000), while I wait to see if my ins. company will pay this.

Thank you!

07-06-2012, 08:40 PM	#1
7andcounting Senior Member Join Date: Jun 2011 Posts: 107	Pertuzumab not avaliable to stage 4 contrary to what you have heard Hi Ladies, This is what I am finding. If you have had Herceptin, then you do not qualify for Pertuzumab. Your ins. company can tell you that you do not need pre-authorization for this drug, b/c IT IS an approved drug, but the FDA approved it in such a way that it is for stage 1 breast cancer. (I am stage 4) You can even get a pre-determination letter. This means nothing, as I have found out. Your company will then send you a letter that says that the pre-determination letter is NOT a garuntee of payment. 1st dose is a loading dose. Cost:$22,000. Next doses are $11,000 every 3 weeks. Until you get your EOB (Explanation of Benefits) back from your ins. co., WEEKS after that 1st infusion, and likely AFTER the 2nd infusion, and you see if your ins. has paid, you will not know if you are going to be stuck paying this yourself. My Oncologist told me I had to sign a paper saying I was liable for this entire amount, if my ins. didn't pay this. My oncologist said the insurance company may come in and after I have already had the infusion, and do what is called, "reto-deny." Drs. give drugs off label all the time, but since this is so newly approved with the FDA it looks like those of us who need this are just plain stuck. Really, I have ins., and I am supposed to sign a letter saying I garuntee to pay this huge bill if my ins. co. decides not to pay? There should be a way that we can be sure that the ins. company will pay----or not. Is there anyone on these boards who works in the ins. industry that could help me? Do you know how I can get the insurance co. to garuntee payment? I needed this drug yesterday! I have orders in at my onc's office to get this, but here I sit in limbo b/c I can not afford to gamble this huge amount of money ($33,000), while I wait to see if my ins. company will pay this. Thank you!