Aetna appeal for Firmagon denial

[Oatmeal2]

My husband was diagnosed with high risk aggressive prostate cancer, Gleason 9. Plus one para rectal node positive. The doctor prescribed 2 years of ADT plus 5 weeks of IMRT. Had first 240 mg dose of firmagon on September 14 with no major side effects so far. Doctor used firmagon to avoid testosterone surge, and after conferring with MO, he agreed to have my husband stay with the firmagon. Today, we receive a letter from Aetna informing us that firmagon is denied and the only drug they approve is Eligard. I’ve been doing a lot of research and find that firmagon appears to be better than Eligard with less side effects. We will file an appeal, I think we can get the first dose approved just based on the known fact of the testosterone flare for Eligard, I’ve also read that some men get micro surges on subsequent doses of Eligard. Has anyone fought with their insurance companies on getting drugs approved and what arguments did you use? I’m ready to print every study I have found and submitting them with the appeal. It’s just so frustrating that an insurance company wants to dictate your health care to you instead of your doctor

[Derf4223]

I'm not a doctor so won't comment on your standoff with Aetna. You didn't mention his PSA #. This is very material. Ditto, PSMA-PET/CT scan results. And age. These would help other members help you here.

But this is beyond dispute: your husband needs to immediately commence daily exercise including resistance/weight lifting and never take a week off from now on. Exercise at this level has been called medicinal. ADT puts ones body into a low/no testosterone state. It doesn't matter much whether he gets firmagon, lupron, etc. It is the low/no T state sans exercise that creates diabetes risk.

Another big guaranteed side effect/risk. Accelerated bone loss due to a low/no T state: very serious stuff especially if he happens to be osteopenic now. He should get a DEXA scan to know where he stands now.

[Oatmeal2 in reply to Derf4223]

Yes we both exercise regularly and are very athletic and aware of all of the negative stuff that comes with ADT. His PSA was 6.5, he is 64 years old, PSMA pet scan showed one peri rectal node with uptake. The initial injection of firmagon was ordered by MO because of the known flares with leuprolide. Aetna should at least pay for this one. In their formulary, they don’t even cover lupron. They prefer eligard I guess because it is cheaper. But if he is tolerating the firmagon well, and some studies show that even subsequent injections of leuprolide can cause micro surges of testosterone how can the drugs be considered equivalent?

[maley2711 in reply to Oatmeal2]

Best I can determine from Google, Eligard and Firmagon are not vastly different in cost?

If all else fails, you could ask Aetna for their pricing on these , and propose to pay the difference? It seems the most outrageous pricing is for Lupron...... not that much less than relugolix/Orgovyx capsules!!

You might find these informative....

redjournal.org/article/S036...

npr.org/sections/health-sho....

Is this an Aetna commercial insurance policy, or a Part D Medicare drug plan?

[Oatmeal2 in reply to maley2711]

Thanks for your input. The Aetna plan is through his employer and it is one of more liberal PPO plans although he is retired. Next year I think it becomes the Medicare advantage plan when he turns 65 which may even be more problems. It used to be a great plan but since they got bought up by CVS, it’s not so great anymore

[maley2711 in reply to Oatmeal2]

Does his employer subsidize the premiums for Medicare Part B and his supplement or enrollment in an Advantage plan? I of course knownothing about your financial situation,but if you don't need employer help, it's time to do some serious thinking/research about his choices for Medicare enrolments.....contact your state's Medicare help people to learn the exact rules that pertain there...speciically aout restrictions for switching betweeen traditional Medicare and Advantage plans.

[Oatmeal2 in reply to maley2711]

Right now he is still with regular Aetna ppo because he is 64. Next year he will be ready for Medicare. I’m almost sure that his employer which is a government agency has a deal with Aetna for all retirees to be enrolled in the “special” Aetna Medicare advantage plan for his union that he retired from. I remember reading about that, although I have to find out if there is an option for traditional Medicare and a supplement

[maley2711 in reply to Oatmeal2]

Hopefully the cost to the union or the employer for his subsidy to be on the Advantage retirement plan could alos be applied to traditional Medicare. My wife is in a similar position........she will have a lump sump to apply toward deductibles,copays, pemiums ,etc for a Kaiser Advantage plan, but unfortunately can' be used for any other Advantage plan or traditional Medicare with a supplemnt......sucks!!!!!!!!!!!!!! I hope you have better options!!! Anyway, at least you say that it will be a PPO Advantage plan, right?

[Oatmeal2 in reply to maley2711]

Yes it will be a ppo medicare advantage plan. It seems that the traditional Medicare and supplement plan will not be available next year with the latest negotiated contract.

[Seasid]

You should know that after stopping ADT with firmagon he would have a quick testosterone recovery.

I believe it is a big advantage.

[dac500]

I have on Lupron since November 2019 with several breaks. During Lupron shortage I was given Eligard couple of times. I found no difference between Lupron and Eligard.

[maley2711 in reply to dac500]

Per my limited Google research, seems Eligard has lower cost than Lupron......wonder why everyone isn't just prescribing /covering Eligard , and not Lupron. Incredibly, on eGoogle result indicated that 8% of Medicare drug costs go toward ADT !!!!!!!!!!!!!!!!!