CVS Caremark Denying Herceptin Coverage

[Missyw]

Hi Everyone,

I just received a letter from CVS/Caremark stating they no longer cover Herceptin unless it is in combination with current chemotherapies (only three types accepted). In other words, no long term use of Herceptin is allowed.

I have been on this life saving drug for about 9 years. I have been NED for five years. Devastated doesn't come close to my emotional state. I am obviously appealing the decision but I don't know how I can continue to receive the Herceptin pending my appeal. My Attorney General's office (MD) indicates there is no legal obligation for an insurer to continue paying for medication while an appeal is pending. Has anyone battled CVS/Caremark and won? If you have any suggestions for resources to help with the fight let me know. I can't believe insurance companies can make life and death decisions so arbitrarily?!

[donocco]

Missy

One thing you can do is to contact your local news-station and see if they will interview you on television. The news will do anything for an attention getting story to increase ratings. If you can humiliate Caremark they may back down, at least in your case fearing financial loss with bad publicity. There may be other suggestions.

Paul

[Jaimieh]

Missy~ I would call your oncologist, your primary insurance and lastly Caremark (I have a very LOW opinion of the people there). They don't just get to decide that they are discontinuing a drug because they don't want to pay. I hope you get your herceptin.

[jellybean]

How awful! This is crazy. I would call your oncologist's office to see if he or she can help. Maybe Genentech could help you with the costs until you get the decision overturned. They have various patient assistance programs. You might also try posting on the bcmets.org board. Maybe someone there has an idea. It seems to be standard practice to stay on Herceptin, so it seems CVS is out of line. Isn't the decision up to the insurance company? I would call them, too.

[SoCalGal]

Don't panic - there are options.
1. contact Genentech's Patient Assistance Program. Genentech can provide herceptin to your doctor's office. There is a simple form for you to fill out and one for your onc, I think your income needs to be under $100,00.00 per year. Your Onc's office should be familiar with the form/format.

2. In addition, have your oncologist write a letter/or contact directly the "independent reviewer" that the insurance usually uses to review these special cases. Your Onc can give concrete reasons why you can't do chemo right now, due to lingering cognitive skill reduction, residual neuropathy and mouth sores that don't easily resolve, and how the consensus is to continue to hold on chemo infusion, but continue CHEMOTHERAPY of Aromasin, etc. Your doc should know just what to say to them.

It's gonna work out - I am sure!!