Orgovyx Insurance Approval

[805guy]

Anyone who is not on Medicare but relying on private insurance in getting approval for Orgovyx? I really want to avoid Lupron or Eligard since I take two blood pressure meds, one statin and Metformin for type 2 diabetes already. Plus, I have heard nothing but bad things about both. Yes, I realize everyone responds differently. If I have to do ADT (12 months), I would like to take the one less likely to cause serious cardio issues. Express Scripts has issued a denial which I intend to appeal. If they do approve, my copay is sky high but I plan to use the discount card the company which makes Orgovyx issued to me for assistance with private commercial insurance copays. If not, I will bite the bullet and fully make my copay. Any similar experiences? How much did you ultimately have to pay out of pocket?

[Vynbal]

I was on Orgovyx for 6 months (June - Nov 2021), w/BCBS Maryland Health exchange insurance policy. They covered it 100% with no copay. Best of luck to your efforts.

[805guy in reply to Vynbal]

You have a great benefit there.

[Tigger2022]

My husband takes it. We have a United Healthcare POS, and they initially declined it a year ago when he started ADT, but his doctor just had to appeal, and it’s been approved since then. His copay is somewhere around $50, I think.

[805guy in reply to Tigger2022]

Appeal by doctor is what will happen. I hear it is how the doctor words it will be a big factor. In my case, I take 2 blood pressure meds, 1 statin and metformin 2 times a day so I would think the lower cardio risk of Orgovyx would be appropriate in my case.

[Tigger2022 in reply to 805guy]

Yes, that makes sense. And I have clarification — he says our copay is $10. He filled out some coupon on the orgovyx website. Good luck!

[Rams91]

I too have had coverage denied by CVS Caremark on two attempts despite my doctor's appeal. First time going on ADT. Does the company's commercial insurance assistance card work only if it is covered by insurance?

[805guy in reply to Rams91]

I’m not sure but it seems as though the company has more than one program as I recall. This whole process of approval for a more beneficial drug overall is such a cruel game.

[watertender]

I am on Orgovyx and have been getting it free from the company based on my income. Get on their webpage and check it out you may qualify and they do have other programs if you have private insurance (not Medicare).

As for side effects it is supposedly better heart wise than Lupron and some of the others and side effects while they are similar may not be quite as bad, of course I have nothing to compare it to.

[805guy in reply to watertender]

Thank you. Fortunately, I have now been approved by my drug plan to receive Orgovyx. I was also told there will be no copay, so this news also makes me very pleased.

[Rams91 in reply to 805guy]

Was your appeal through a different doctor or the same? I'm thinking may be my MO did not do a good job making a case for the drug.

[805guy]

That may be the case. Mine was initially rejected but accepted on appeal. I believe the doctor has to use just the right wording whatever that might be. In my case I listed my BP meds, statin med and metformin to my doctor as an argument for orgovyx. Not sure if that's what changed the decision. Good luck.