HER2 Support Group Forums - View Single Post - Insurance Company Does Not Want to approve TYKERB

hutchibk · 10-07-2009, 05:28 PM

Sheila, please read my post. It has the solution I used when I was in your shoes, and it explains that if the Government doesn't cover it, neither will private in many cases.

I do now get it through Medicare, but under Part D, with the donut hole. And I get it with Herceptin, without Xeloda. Tell BCBS that Medicare Prescrip Part D approves it by itself with Herceptin... that may get their attention. I asked my Onc how we were able to get me on Ty/Herc and he said that since they are each FDA approved, it doesn't matter that the combo is not FDA approved...

Also, send them an appeal letter discussing that Medicare covers it under Part D without Xeloda... cc: your state board of insurance and follow through with a copy to the state board of insurance. That is a pretty effective way to get their attention.

Find out if there is a pharmaceutical advocate at your clinic... mine is a US Oncology affiliated clinic, and my nurse advocate was my lifesaver in helping me gain access to Tykerb. http://www.usoncology.com/portal/pag...nce/A_Patients

Just to clarify, BCBS is denying it through your prescription benefit, right? It's not through your medical benefit?

You can probably get it through GSK Access to Care. Email Joe... there may be a compassionate use angle for you in combo with Herceptin.

Also, they are preparing to enroll for a trial of Tykerb/Herceptin for mets patients... do you qualify?
http://clinicaltrials.gov/ct2/show/NCT00968968

10-07-2009, 05:28 PM	#14
hutchibk Senior Member Join Date: Oct 2005 Posts: 3,519	Re: Insurance Company Does Not Want to approve TYKERB Sheila, please read my post. It has the solution I used when I was in your shoes, and it explains that if the Government doesn't cover it, neither will private in many cases. I do now get it through Medicare, but under Part D, with the donut hole. And I get it with Herceptin, without Xeloda. Tell BCBS that Medicare Prescrip Part D approves it by itself with Herceptin... that may get their attention. I asked my Onc how we were able to get me on Ty/Herc and he said that since they are each FDA approved, it doesn't matter that the combo is not FDA approved... Also, send them an appeal letter discussing that Medicare covers it under Part D without Xeloda... cc: your state board of insurance and follow through with a copy to the state board of insurance. That is a pretty effective way to get their attention. Find out if there is a pharmaceutical advocate at your clinic... mine is a US Oncology affiliated clinic, and my nurse advocate was my lifesaver in helping me gain access to Tykerb. http://www.usoncology.com/portal/pag...nce/A_Patients Just to clarify, BCBS is denying it through your prescription benefit, right? It's not through your medical benefit? You can probably get it through GSK Access to Care. Email Joe... there may be a compassionate use angle for you in combo with Herceptin. Also, they are preparing to enroll for a trial of Tykerb/Herceptin for mets patients... do you qualify? http://clinicaltrials.gov/ct2/show/NCT00968968 __________________ Brenda NOV 2012 - 9 yr anniversary JULY 2012 - 7 yr anniversary stage IV (of 50...) Nov'03~ dX stage 2B Dec'03~ Rt side mastectomy, Her2+, ER/PR+, 10 nodes out, one node positive Jan'04~ Taxotere/Adria/Cytoxan x 6, NED, no Rads, Tamox. 1 year, Arimadex 3 mo., NED 14 mo. Sept'05~ micro mets lungs/chest nodes/underarm node, Switched to Aromasin, T/C/H x 7, NED 6 months - Herceptin only Aug'06~ micro mets chest nodes, & bone spot @ C3 neck, Added Taxol to Herceptin Feb'07~ Genetic testing, BRCA 1&2 neg Apr'07~ MRI - two 9mm brain mets & 5 punctates, new left chest met, & small increase of bone spot C3 neck, Stopped Aromasin May'07~ Started Tykerb/Xeloda, no WBR for now June'07~ MRI - stable brain mets, no new mets, 9mm spots less enhanced, CA15.3 down 45.5 to 9.3 in 10 wks, Ty/Xel working magic! Aug'07~ MRI - brain mets shrunk half, NO NEW BRAIN METS!!, TMs stable @ 9.2 Oct'07~ PET/CT & MRI show NED Apr'08~ scans still show NED in the head, small bone spot on right iliac crest (rear pelvic bone) Sept'08~ MRI shows activity in brain mets, completed 5 fractions/5 consecutive days of IMRT to zap the pesky buggers Oct'08~ dropped Xeloda, switched to tri-weekly Herceptin in combo with Tykerb, extend to tri-monthly Zometa infusion Dec'08~ Brain MRI- 4 spots reduced to punctate size, large spot shrunk by 3mm, CT of torso clear/pelvis spot stable June'09~ new 3-4mm left cerrebellar spot zapped with IMRT targeted rads Sept'09~ new 6mm & 1 cm spots in pituitary/optic chiasm area. Rx= 25 days of 3D conformal fractionated targeted IMRT to the tumors. Oct'09~ 25 days of low dose 3D conformal fractionated targeted IMRT to the bone mets spot on rt. iliac crest that have been watching for 2 years. Added daily Aromasin back into treatment regimen. Apr'10~ Brain MRI clear! But, see new small spot on adrenal gland. Change from Aromasin back to Tamoxifen. June'10~ Tumor markers (CA15.3) dropped from 37 to 23 after one month on Tamoxifen. Continue to monitor adrenal gland spot. Remain on Tykerb/Herceptin/Tamoxifen. Nov'10~ Radiate positive mediastinal node that was pressing on recurrent laryngeal nerve, causing paralyzed larynx and a funny voice. Jan'11~ MRI shows possible activity or perhaps just scar tissue/necrotic increase on 3 previously treated brain spots and a pituitary spot. 5 days of IMRT on 4 spots. Feb'11~ Enrolled in T-DM1 EAP in Denver, first treatment March 25, 2011. Mar'11~ Finally started T-DM1 EAP in Denver at Rocky Mountain Cancer Center/Rose on Mar. 25... hallelujah. "I would rather be anecdotally alive than statistically dead." Last edited by hutchibk; 10-07-2009 at 05:51 PM..