Help-Advice needed to get Ins To pay for Projeta
 

Hi everyone
I'm having a really bad time, saw Onc yesterday to review PET. She walked in and said its horrible much much than she expected. I am lighting up in many places including 2 spots on liver.
I finished 4 doses of Kadcyla and the cancer grew like wildfire during that time. The new plan is Taxol, Herception and Perjeta. The financial person said Aetna would pay and then called back and said she thinks it's going to be a problem, how cruel!
Anyone have any insight as to how I might get this approved, when I asked the Onc how long I would have with no treatment she said weeks to.3 months. I'm terrified to say the least .... Any advice is appreciated.
Pat
I also have Blue Cross of CA as secondary ins

Re: Help-Advice needed to get Ins To pay for Projeta
 

PatE,
In your mind, try to rephrase the words your oncologist used. "OK. There is progression. We can handle this." Erase "horrible." Erase "much more," which is what I think you meant to write. You have enough to deal with without adding a poor bedside manner. Phew. That even knocked the wind out of me.
Don't expect to have a problem with the insurance company. Let them know you won't settle for anything less than what you need. If your oncologist says you need it, you need it. And speak with a supervisor. Ask for decisions in writing if you are given the negative.
Can anyone in Patient Relations help you get what you need? I find that the Billing/Insurance department at my facility gets a lot done for me. I'd go that route. Ease up any burdens on yourself.
Wishing you all the best,
Karen

Re: Help-Advice needed to get Ins To pay for Projeta
 

KDR,
Thank you for the quick response and kind words. I agree its time for a new Onc! I have called my company benefits Manager, my insurance advocate at the ins company - got all voice mails so waiting for call backs.

I found this on the FDA website - a news release dated Sept 30th, 2013

"Perjeta new use is intended for patients with HER2 positive locally advanced, inflammatory or early stage Breast cancer (tumor larger than 2cm in diameter or with positive lymph nodes) who are at high risk of having their cancer return or spread OR OF DYING from the disease"

Did you have any problems with ins and how was Perjeta
Thanks so much, I'm trying to stay calm.
Pat

Re: Help-Advice needed to get Ins To pay for Projeta
 

Pat,

I have no experience with insurance companies, so no help on that front, but I have added you into my prayer notebook so I will remember to pray specifically for your healing and for a swift end to your insurance log jam.

I completely agree with Karen regarding your Onc's negative bedside manner. Honestly! Karen's words were so well said and clear that I cannot add more except to say that I will go to my knees for you.

Laurel

Re: Help-Advice needed to get Ins To pay for Projeta
 

PatE,
I think it took a week to get approval. They (your medical professionals) know how to get it done. Believe me, they want the money. You might have a great oncologist, just one who can't seem to channel unfavorable news with empathy. If this oncologist were mine, we'd have to talk about "how" to talk with me. Not TO me. Not AT me. WITH me.
Press on.
Karen

Re: Help-Advice needed to get Ins To pay for Projeta
 

Maybe this will help. I know we got Blue Cross in Washington State to cover Perjeta. This link is Blue Cross policy re pertuzumab (perjeta) from "Capital Blue Cross" in Pennsylvania:
https://www.capbluecross.com/wps/wcm...df?MOD=AJPERES

I. POLICY

The use of pertuzumab may be considered medically necessary in the treatment of breast
cancer when all of the following conditions are met:
 Patient has HER2–positive metastatic breast cancer
 Pertuzumab is used in combination with trastuzumab and a taxane (e.g., docetaxel,
paclitaxel)

2. This is Blue Cross Blue Shield's position paper on Pertuzumab
https://www.bcbsnc.com/assets/servic...pertuzumab.pdf


Pertuzumab (Perjeta™) is a monoclonal antibody that is a HER2 receptor antagonist. It has received U.S.
Food and Drug Administration (FDA)-approval for use in combination with trastuzumab and docetaxel
for the treatment of HER2 positive, metastatic breast cancer. The combination of 2 HER2-active agents
targeting different subdomains of HER2 may result in a more comprehensive blockade of HER2 and its
pathways, and thus may lead to a greater treatment effect.

GOOD LUCK!

Re: Help-Advice needed to get Ins To pay for Projeta
 

speak to asupervisor , take name, record of call, get a copy of their coverage rules regarding perjeta. fda approval is for pts who have not had prior anti - her2 therapy, but many ins. co.'s are approving it, like that bc/bs mentioned. docs can prescribe it for stage iv's who have had prior anti -her2 tx., its called " off protocol or off label " . the fda pt reps tell pts this , they understand their appr. process is not keeping up w/ new tx.'s. their top execs , all dr's ( amazing ) pazdur, woodcock, hamburg, are too far removed from the chemo room reality. their fda has " no timetable " right now to "expand label " . this is crux of our activism. we stage ivs have no voice at top of fda.
so we fight . push the ins. co., for a week or so, appeal any denial. then go to your Congressional reps, and media. are u at a top research hospital , dealing w/ latest triple pos., which it looks like u are ? your doc doesn't sound like a top researcher .

Re: Help-Advice needed to get Ins To pay for Projeta
 

make sure to tell Aetna how cheap their coverage looks compared to that bc/bs.

Re: Help-Advice needed to get Ins To pay for Projeta
 

a hospital dealing w/ trials for triple pos , new tx's are coming out every yr now.

Re: Help-Advice needed to get Ins To pay for Projeta
 

Thanks everyone for all the great advice. Aetna is paying for the Projeta! Had my 1st treatment, praying this is my magic bullet!
You guys are wonderful, don't know what I would do without this site!
Pat