Does Medicare Cover Pluvicto Treatments

[roboocme]

My husband is scheduled to start Pluvicto in November. We know it is expensive and wonder how those on the site who have had it paid for it. Regular insurance? Medicare? other?

[Tall_Allen]

Yes, it's covered by Medicare and most insurance as long as the patient has failed one advanced second-line hormonal therapy, tried chemo, and is PSMA-avid.

[lokibear0803 in reply to Tall_Allen]

Wondering about the specifics around that phrase “tried chemo”. Does that mean a patient can do one infusion, determine that they can’t tolerate it, and qualify for Pluvicto?

[Tall_Allen in reply to lokibear0803]

Yes.

[tango65]

Yes, it is covered by regular medicare part B based in medical necessity. I never had chemo and they had pay for 3 treatments so far.

[lokibear0803 in reply to tango65]

Hi tango - so if I recall, you got some kind of exemption from chemo related to neuropathy, am I right? Is there some threshold of severity that’s required by Medicare for this?

Thanks -

[tango65 in reply to lokibear0803]

I don't know.

If one has a neuropathy one should not have chemo with taxanes which could cause neuropathy in about 30% of patients, if there is other treatments available.

Regular medicare, uses medical necessity to decide payment for treatments approved in the USA.

[lokibear0803 in reply to tango65]

how did you establish “medical necessity”? it seems you were able to find a way around the chemo requirement -

[tango65 in reply to lokibear0803]

I did not establish medical necessity. I talked with the insurance company managing regular medicare part B and they told me that they not necessarily follow FDA criteria.

If the treatment is approved, they decide based on medical necessity determined by their own experts according to the clinical situation of the patient and the recommendations of the treating physycian.

They have all your medical information.

[spolyu in reply to tango65]

Dear Tango,

Every doctor tells me that I must get at least one Chemotherapy treatment in order for Medicare to pay for Pluvicto.

Where did you get your treatment done and how did you get this treatment Pluvicto with no Chemotherapy?

Your response is very appreciated.

Thank you

[tango65 in reply to spolyu]

Hi:

Further information about me, it is not going to change the fact that Noridian one of the companies managing Medicare parts A and B decides payment based on clinical/medical necessity.

They do not decide based exclusively in the FDA criteria used to approve a drug or treatment. That they only use those criteria to decide payment is a misconception.

Get in touch with Noridian, they have many web pages and email addresses.

[spolyu in reply to tango65]

Thank you very much

[leebeth]

My husband and my brother both had it covered 100% with traditional Medicare and a Plan G supplement. No prior auth needed.

A Medicare Advantage plan would require a prior auth, and depending on your plan, would have a copay until you reach your max OOP each year.

[Tjc1]

My oncologist hooked me up to the manufacturer of Xtandi.

[j-o-h-n]

Here we are............. living in America, and worrying about some guy siting in an office watching porno videos and making decisions regarding our lives......My two brothers and I spent years in the military protecting these guys without them having to worry their asses off... All I can say to these guys is "Duck and Cover"......

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 10/30/2023 8:25 PM DST

[j-o-h-n]

We know it is expensive and wonder how those on the site who have had it paid for it.

Wonder no more robo...... Those illegal immigrants are going to chip in and pay for it....

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 10/30/2023 9:04 PM DST