Insurance Company Does Not Want to approve TYKERB

Sheila · 10-07-2009, 09:35 AM

OK, today is day 9 since Tykerb was ordered, the insurance company, BCBSIL and CVS/Caremark is not wanting to approve because it was not ordered with Xeloda.....gee, I was on Xeloda and failed, I just cant understand why the pharmacy at Caremark is dictating my treatment regimen instead of my Oncologist. In the meantime, the lump in my neck continues to grow...after 4 phone calls today and getting no where, I finally lost it and broke down in tears....now maybe they can give me something for stress while they decide whether or not to approve something to help me fight this damn cancer.
Hoping tomorrow is a better day.

Mary Anne in TX · 10-07-2009, 09:50 AM

Are they completely NUTS?????
Sometimes I think those "guys" live on another planet!
Will your doctor call them? That's what it took a couple of times
for me to continue my treatment!
I'm praying for quick action and someone getting appropriately angry!
Luv ya, ma

Shobha · 10-07-2009, 09:55 AM

This is really the limit!! I pray that they will approve it right away and you get some peace. This is so cruel.

Love,
shobha

AlaskaAngel · 10-07-2009, 10:19 AM

Sheila,

While you get your doc to deal with the insurance company, try to see if the drug company, under the circumstances, will consider providing it to you.

Wishing every bit of good comes your way,

A.A.

tricia keegan · 10-07-2009, 10:41 AM

Sheila, a friend of mine recently had a similar problem when she tried to get avastin approved without xeloda, she lives in Florida.
In the end she had to take the xeloda with it which was ridiculous as she had spent eleven years on chemo and needed a break.
I can't offer any advise on insurance companies to you, but hope your onc can take it up with them on your behalf??
Why not have him order the xeloda and just not take it but use the tykerb??
I'm sorry you're upset and realize the last thing you need right now is to stress about this!

StephN · 10-07-2009, 11:08 AM

Dear Sheila,
I am sorry the "powers that be" are being such BUTTS! This is the last thing you need to worry about.

There is something called "Tykerb Cares" that should help you. Your doc's nurse may have to get into the act, but I have heard of results from that sector. More phone calling is not what you need, but I know YOU are expert at working these things out.

Has the FDA approved Tykerb ONLY when taken with Xeloda?? What about the gals getting Tykerb with Herceptin, etc?? Puzzling.

schoolteacher · 10-07-2009, 12:28 PM

Shelia,

Hope you get the medicine soon. Maybe the people Stephanie is talking about will help.

Amelia

michka · 10-07-2009, 12:38 PM

Sheila, I am so mad. How can they deny you half a treatment when they are ready to pay for Tykerb AND Xeloda?? Well, if that's what they want, have your Doctor prescribe Tykerb and Xeloda and only take Tykerb. You don't need this kind of stupidity on top of worrying about the treatment. I send you hugs and hope they will realize how ridiculous this is. Michka

Carolyns · 10-07-2009, 01:30 PM

Sheila,

This is SO wrong! Just another way to get around paying for treatment. I wish I had a bottle to send you.

My doctor shared with me how much harder it is getting every day to get what she needs for her patients via the insurance companies. She said she can spend half of her day explaining why she needs to get authorization for her patients. It is like the doctors have to adovcate and prove that we need what we need. I wonder how many doctors just run out of time to fight the insurance company.

I hope this gets resolved soon. It is so wrong.

Love, Hope, Peace, Carolyn

hutchibk · 10-07-2009, 03:11 PM

It is considered pharmaceutical... so your "medical plan" under insurance that pays for infusion chemo will not pay for it.

Quite simply and disgustingly, this is because MEDICARE doesn't pay for it either. Insurance companies are allowed to, and do (to a lesser degree I promise), follow Medicare guidelines and restrictions and denials. I can't blame them... Medicare has been established as the "coverage model" for the whole system, including private.

Medicare doesn't pay for it under part B "medical plan" (the outpatient part of the Medicare plan).

If you have Part D with Medicare, it pays for it up to the donut hole, which is only about 3/4 of a month's worth, then you carry the responsibility through the donut hole ($3500 I think) until it is covered again.

When this happened to me when I was still on BCBS, my pharmaceutical nurse advocate at my cancer clinic helped me fill out the paperwork to gain access to it through GSK Access to Care, and she finessed the process for me.

Find your pharma nurse advocate and get them to help you.

Welcome to the shape of things to come.

Sheila · 10-07-2009, 04:03 PM

Well, the insurance called this afternoon with their "denial reasoning". Seems they will not pay for the Tykerb as it is only approved with Xeloda....if I get the Xeloda, they won't pay for the Herceptin...its a catch 22. Seems that the Oncologists should be dictating our care and not the Pharmacys or the insurance companies! Enough tears for today, tomorrow is another day, and the fight will continue. Keep me in your prayers!

Bill · 10-07-2009, 04:12 PM

Sheila, all I can do is reiterate what everyone else has already said. Have your doctor call, and you keep calling, contact the pharmaceutical company, and maybe check with your chemo. nurses and "others". Sometimes they may receive donations of medications that patients no longer need. You hang in there, girl!

chrisy · 10-07-2009, 04:37 PM

You're right - your doctor should be making the decision! Assuming she has a rationale for this combo (which I know she does), can she help with providing this, along with whatever data there is supporting this.

maybe Flori or some of the others on this combo can give you some additional ammo as well.

To start, could you get the Tykerb with Xeloda while you're pushing for the Herceptin as well? Even though Tykerb/Herceptin failed you, you may still get some synergy with Xeloda. Think of it as swapping out the Herceptin piece?

Keep pushing for the combo, but you shouldn't be naked. Here's a couple of links that may help support your case.

http://professional.cancerconsultant....aspx?id=42119

http://kinasecentral.wordpress.com/2...-increase-pfs/

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

Joe · 10-07-2009, 05:52 PM

Brenda and All,

We are working on this.

Rgards
Joe

hutchibk · 10-07-2009, 05:57 PM

wonderful... Joe rocks.

Laurel · 10-07-2009, 06:22 PM

Sheila,

I think the log jam will break with such amazing warriors as Joe and Brenda behind you! Good luck!

WomanofSteel · 10-07-2009, 08:17 PM

As if it isn't bad enough that we have this crappy disease to begin with, we have to have the stress of battling it out with insurance companies just to fight it. I hope that the doctor is able to help you. If not, the ladies had some good advice. Good luck!

Joan M · 10-07-2009, 08:30 PM

Sheila,

You don't deserve this. I would involve your onc to help in getting the recommended treatment without any strings attached.

Joan

RhondaH · 10-08-2009, 01:36 AM

Sheila,

Stinks that you have to fight cancer AND the insurance company, but have the doc write letters, make phone calls, do as Steph says and call for compassionate use. I hope this gets resolved quickly and that you will be able to use that time to play with those wonderful grandchildren of yours. HUGGLES!!!! Take care.