Orgovyx denied by insurance, husband has heart failure

[JLR65]

My husband recently had RALP and unfortunately the PSA didn’t drop and PSMA scan revealed a few lymph nodes in the pelvis. He will be having 39 sessions of radiation and ADT. He has early stages of heart failure and the doctor wants him on Orgovyx due to fewer cardiac effects. Our insurance has denied us. We have Blue Cross Blue Shield through the Exchange. Thankfully his urologist has given him “sample” bottles and he has been on it for a week now. The urologist said to come pick up a refill of the samples again next month. They are hoping to get this denial reversed. Any experiences on successfully reversing a denial?

[fireandice123]

I’ve not been denied for meds but I was initially denied for RT and a PSMA scan. Both were eventually approved. For the PSMA scan my MO worked with the BCBS to get it approved. Had to have a CT and a bone scan before they would approve it, which I did and they approved the PSMA.

The RT denial required that I go through through the appeal process, which in Vermont can be three rounds of appeal. The first two were appeals directly to the insurance company, which, no surprise, were denied. The third appeal was to an external independent third party. That was approved. Essentially the same information from my RO explaining why I needed RT was used for each round.

Good luck.

[j-o-h-n]

Insurance should be renamed to Outsurance...........

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 02/23/2023 7:07 PM EST

[Hidden]

That isn’t right at all! Sorry ! 😤