Please help! Tykerb has been denied by CVS Caremark

Barbara H. · 01-11-2010, 02:35 PM

I am on my third month of taking Tykerb with Herceptin. Unfortunately, my husband's mail order perscription plan has changed to CVS Caremark. My oncologist sent in the prescription on Dec. 30th and I will run out of tablets by the end of the week. This medication is working for me, and I am totally stressed knowing what Shiela went through. Shiela can you give me some advice. I was on the phone with them today and said that I was going to take some action if they did not send me my prescription soon.
Sadly,
Barbara H. (See below)

Dear Dr. Krop and Danielle,

I was just on the phone to a customer care representative, Ivana, at CVS Caremark (where Care appears not to be a mark of excellence...), who informed me that your long-term prescription request has been denied by Caremark's review board.

According to Ivana, DFCI and Dr. Krop will have to initiate an appeal's process, apparently justifying your medical care decisions. You should have received (or will eventually) a notification of this denial by Caremark. Please request this appeal as soon and as vehemently as possible, since Barbara's supply of Tykerb will only last until next Monday (which is a holiday).

jml · 01-11-2010, 03:18 PM

Hi Barbara~

I'm so sorry that you're dealing with this frustration!
I hope your appeal is swift & successful.

I learned that I don't have Rx coverage for this med & as you know, it VERYVERYVERY expensive!!
I struggled to pay out of pocket, while I applied for Pt. assistance, but the process was fairly long & frustrating.

Just in case, GSK has a program called "Committment to Access" that will provide your TYKERB for free.
(The other program "TYKERB Cares" will only offer you CO-PAY assistance - which means, if you dont have Rx coverage, they won't help you.)
You'll need your social worker to initiate the application, but once you are able to provide the appropriate paperwork, they move pretty quickly, and will even overnight the med to you if needed.
Maybe you could get the ball rolling with the social worker while your MD helps you appeal.

I hope this info is helpful.

Good luck & wishing you the best outcome!

Jml

hutchibk · 01-11-2010, 04:09 PM

I believe what Sheila had to do was have her doctor write the script for Tykerb and Xeloda (which is the FDA combination they require you to be on to approve the Tykerb as Hercptin/Tykerb is not yet an FDA approved combo), and even though you don't need and won't take the Xeloda (don't tell them that and yes it sounds like a huge waste of money), they should cover it. My pharmaceutical advocate nurse advised and helped Sheila figure out the course of action...

Sheila should be posting on this soon and will be able to give you much more insightful details.

Sheila · 01-11-2010, 04:28 PM

Barbara
This sounds so familiar, as I had to deal with CVS Caremark...I went through GSK's programs, and they were of no help. All that happened was more time was wasted. My Oncologist had to write an appeal, which they denied, and then I wrote my own appeal, and I was approved. Please send me a phone # via private message...I can fax you all the paperwork I used and you can see what my appeal looked like and who I sent it to.
By the way, mine was ordered as a solo agent to be taken with Herceptin therapy, and WITHOUT Xeloda. My onc. would not order the Xeloda just to get it approved, but if yours will, thats another way around it!

WomanofSteel · 01-12-2010, 10:32 AM

I am curious to see what is going to happen to me now. My onc is switching me to tykerb/xeloda due to yet another progression. I also have CVS Caremark. I am anxious to see if they approve this since Sheila said they would have for her. Good luck Barb.

Sheila · 01-12-2010, 10:49 AM

WOS
You should be able to get the Tykerb/Xeloda with no problems..its when they want to give the Tykerb with Herceptin that CVS has issues....Barb emailed me and I faxed her husband 23 pages of appeal info I used....hoping it works for her as it did for me!

Hoping the Tykerb/Xeloda is a good new combo for you WOS~~~

Chelee · 01-12-2010, 03:36 PM

I do not want to take this thread off topic...but looks like Shelia has helped her out. But can someone tell me WHY CVS or any pharmacy would have a say in what drug your allowed to have? The drugs/medications we are prescribed are from our doctors...not our pharmacy...so how are they allowed to stick their nose in our business?

I'm using CVS...but I pick up my meds at the store so far. But if you use their prescription mail order plan then they can deny your meds/drugs? This doesn't seem right...these drugs can be a matter of life and death. How are they allowed to do this? We have enough stress in our lifes without worrying about getting a notice at the last minute saying you can't have your prescription. Unbelieveable.

Chelee

Barbara H. · 01-12-2010, 04:09 PM

Hi Chelee,
I spent a lot of time on the phone yesterday to Caremark.
Apparently when my husband's work switched to Caremark, they authorized this pharmacy to only approve drugs that meet the protocol. Therefore, I was denied. My husband is currently discussing the issue with his work, and my oncologist is also appealing the case. Sheila has also sent me information that should help my personal appeal, if this is not solved in the next few days. I am also considering switching to the health care plan my school system offers. Up until now I didn't want to do that in case I had to leave work.

I believe that this could be a major issue for all of us in the future as more targeted therapies are developed that may only be available in the form of tablets.

Best regards,
Barbara H.

StephN · 01-12-2010, 08:09 PM

Gee, Barbara -
I am appalled at your treatment by a *gosh darn pharmacy.* Guess I assumed you had your health plan through your school, but see where if you had an alternative that might be better.

Your time to fight this is limited due to your work, so I hope you will have a resolution quickly!

The health plans need to reclassify or create a NEW classification for some of these new drugs.

Best thoughts coming your way on this one.

WomanofSteel · 01-13-2010, 06:33 AM

Thanks Sheila, right after I read your post I got a call from Caremark saying it was approved. It is going to cost me 1,101.00 for the 1st month. After my deductible is reached and my out of pocket, the cost should come down. If not I will definitely need some help paying for this.