Trouble Getting Insurance Approval for Ibrutinib in the US?

[NPBonsai]

Has anyone else had trouble getting Medicare (part D through WellCare) to approve their prescription for Ibrutinib? I was prescribed it 3 weeks ago and I am still trying to get it approved. Thanks!

[lankisterguy Volunteer]

Hi NPBonsai,

-

With several of my past prescriptions for Ibrutinib, Venetoclax etc. My CLL Expert doctor & his staff had to respond to questions from the Insurance company before they would approve. -

And many times the Insurance company insisted that they sent a fax to the doctor but got no response- which the doctor denied.

-

From all my past dealing with insurance companies, I suspect they have an unwritten policy of denying, denying, denying and trying to wear down the patient.

-

You may want to ask your CLL expert doctor to intervene- many of them have staff support that knows how to play the "insurance game"

-

With Ibrutinib the drug is usually supplied by one of 4 specialty pharmacy providers: Avella, Biologics, Diplomat or Onco360, and that choice is made by the Hospital, so getting your insurance to approve the payment to the speciality pharmacy is often the hitch.

-

If your doctor's staff will assist you, then the same people can help with getting your CoPay assistance from a non profit like Patient Assistance Network.

-

Len

[KkCreative in reply to lankisterguy]

Len, Thank you so much for your very helpful response to my husband's question. We're on it again this morning, so hopefully we'll get some traction soon. We've been at this since Jan. 4.

Kindest thanks to you,

Kami

[cllady01 Former Volunteer in reply to KkCreative]

I have the same Part D insurance, so I would be interested in the outcome of your efforts--both the route you had to take and the share of the cost the insurance co. accepted.

It is so infuriating that you have to go through all this to get care you are paying for.

Best wishes for a quick resolution with the Drs office help. I do hope your husband is seeing a CLL specialist, most of them do have the assistance within their staff and the specialty pharma to handle the details.

[Smith123456 in reply to cllady01]

Medicare part d-must pay for imbruvica,venclexta. However most insurance company computers are flagged for high cost drugs and require a prior approval for imbruvica because of the high cost not the drug itself. the insurance company cannot turn it down if-the doctor responds to the prior approval form. In my experience as a retired retail pharmacist-most of the time is getting the doctor to respond at all-or incomplete information on the approval form. i f you look at your formulary online you will see the insurance has 3 business day to respond. in the case of part d it's a formality-but i suspect it's the doctors office. If you call the prescription processor i suspect they will tell you they are waiting for doctor prior approval form.

[Smith123456]

another question. are you sure it's being rejected or are you questioning the 2800 dollar copay. That is the correct co-pay on the first filling of imbruvica . Part d resets to 0 every january. they may be looking to get you co-pay assistance . Your total YEARLY co pay on part d for this will be 11,000 dollars. the pharmacys get this so rarely that they think it's going to be monthly

[pragnar in reply to Smith123456]

Hi Can you buy any supplemental insurance to cover the 11000 co pay? As I am nearing the Medicare age I am trying to prepare for the financial expenses related to my medication. Also to whom do you apply for financial assistance with co pay? Is it drug company?

[lankisterguy Volunteer in reply to pragnar]

Please start applying for Medicare 3 months before your 65th birthday. Your state will have a Medicare funded program to advise/train/help you with the process. medicare.gov/contacts/

-

It is a complicated minefield to navigate, and the drug companies are prohibited from assisting Medicare recipients directly. -

Some of the CLL Experts have staff that can guide you to the specialty pharmacies that distribute Ibrutinib to their hospital. And from the specialty pharmacy, then on to getting non-profits like Patient Assistance Network

panfoundation.org/ for copay assistance.

-

Another good way to start is by contacting the lls.org/

Speak to an Information Specialist

For personalized disease and treatment information and clinical trial searches.

Monday - Friday 9 am to 9 pm ET.

1.800.955.4572

Live chat

Email

lls.org/support/financial-s...

-

Len

[Smith123456 in reply to pragnar]

Pan foundation, lymphoma and leukemia society -there are a few others. you can also apply directly to imbruvica or venclexta manufacturers. they will by pass your insurance all together and give you imbruvica or venclexta free-since they can't affect your co-pay under the law. i get mine currently from them. it's not a forever deal though. you have to stay one step ahead. also spending some money on part d even if you don't have to sometimes will avoid needing approvals in the next year. my medicare advantage plan -at the moment-guarantees no approval hassles if at least one filling of a drug in prior year. all this stuff is at this time. things change. i have no idea if you can buy co-pay policy-because there is no cap on catatrophe part of part d. i haven't found one but there may be some. also if you get retiree insurance from your employer or are poor enough for some other coverages you may be able to avoid it.

[Corkyrissa]

I have WellCare all I had to do was call them and that was it. It’s something I do every year just to make sure.

[NPBonsai in reply to Corkyrissa]

Thank you

[pragnar in reply to Corkyrissa]

What is WellCare?

[Corkyrissa in reply to pragnar]

Hi. Well are is a part D insurance that covers prescription medications.

[BallyB]

I started acalabrutinib, a similar drug, a few moths back. The clinic sent the pre authorization request while I was in the office and the approval was in my e mail by the time I got home.

[Hidden]

I am about to start treatment with V + O, and was very concerned about the possible costs. I applied to the Pan Foundation and the CLL Society for grants to cover the cost of the drugs, and was awarded grants. I have Medicare A + B and an United Health Care supplement. My oncologist called the insurance company, and they said they will fully cover the costs! It did take about 30 minutes of his time, for which he charged the insurance and they paid. When I called myself I got a different answer, that the Venetoclax only would be $2250/mo... So now I don't need the help from the Pan Foundation or CLL Society, so someone else can use it. The United Health Care Medicare Supplement is really good, for me here in Hawaii, my total costs for care are capped at $198/year (plus my monthly premium $167, RX coverage $78). Last year I went to Washington to consult a specialist and the UHC plan there had better coverage.