Did you use Orgovyx with radiation, and did your Medicare Part D or Advantage plan cover it ?

[maley2711]

I'm hoping to learn what roadblocks anyone encountered in asking to use Orgovyx instead of Lupron, etc as part of radiation treatment. Resistance from prescribing ROs? Problems with Part D drug coverage ? Advantage plans...Kaiser , etc............that would and wouldn't cover at least some of the $2700/mo cost?

Did any ROs actually advise using Orgovyx instead of Lupron, etc? Did briefly discuss this topic with my current Kaiser RO, and he correctly mentioned that all studies of effectiveness of ADT + RT were based on Lupron, etc.......so 12 months of Lupron may not be the number of months that orgovyx should be used to achieve the same effectiveness. T remains low much longer after 12 months of Lupron than after 12 months of Orgovyx.

Thanks for your help with this!!!

Dale

[Murk]

My RO who I researched to be one of the best in the USA Mid Atlantic strongly recommended Orgovyx because it works well, has less side effects and allows a quick recovery.

In the USA Medicare Advantage plans may not cover Orgovyx but the the standard plans through Medicare like WellCare are fine with it. I now have WellCare now and they didn't balk at all.

Not here come the interesting part... I didn't have a drug plan (through Medicare) so I quickly signed up but the beginning was January of 2024. Its crazy I could not get any pharmacist to tell what the price was gonna be under a Medicare / WellCare plan beforhand! So here is what happened...

In early November I didn't have a drug plan yet because sign up was for January 1st. So Onco360 online pharmacy gave me a FREE 30 day supply. That lasted one month then I paid them the retail standard Onco360 $3,100 in December for another one month supply!

Then My Drug plan from WellCare took effect on January 2nd and I paid $571 for a 30 day supply, and every month after. Besides the crazy freaking prices I could never get anyone anywhere to give me a price before I was in a drug plan other then their standard list retail price of $3,100 for 30 day supply.

Now that I have seen the bills flow by and see that Medicare is picking up a large portion of the drug prices and I was billed $571 versus 3,100.

I will say Orgovyx works and side effects are minimal. I smile know that when my son inherits this disease 20 years from now treatments and will be so much better

[maley2711 in reply to Murk]

Congrats and thanks for that help!!!! How many months of ADT will you have with your Orgovyx?

Check with your D plan.... after you hit approx $3300 from your pocket, there should be no more costs for you!!...and in2025, that goes down to $2000-$2500 under the Biden Inflation Reduction Act.

So, you didn't even need to mention Orgovyx to your RO.....he immediately advised its use instead of shots? You had no pre-existing CV diagnosis that would have prompted that advice?

Did he mention that there are no long-term studies comparing disease outcomes when Orgovyx is used vs injectables? One objection is that, eg, 12months of injection ADT is not equivalent to 12 months of Orgovyx. Men will remain castrate for a longer time past the 12 months when injection is used versus when Orgovyx is used......so should men using orgovyx with RT do the Orgovyx for 15-18 months vs the 12 for the injections???? That was the issue raised by my Kaiser MIT and Harvard-trained RO.

He did not absolutely say no.....I didn't push it and wemoved on to the next topic. However , I'm trying to find some more ammo for additional discussion with him re Orgovyx possible use. Other user experinces can be part of that ammo!!

Thanks again.....and be sure to confirm that $3300 max for 2024 !!

[dhccpa in reply to Murk]

You can search the Medicare site before you even purchase a Plan D plan to find out how much drugs will cost at each pharmacy.

[Murk in reply to dhccpa]

Since I was not in a drug plan but researching in October 2023 for costs in 2024 that info wasn't available yet.

[Laun in reply to Murk]

By Oct15 you can see all the drug plans and prices for the next year. The medicare site will show what is covered also. Also check with MFG. to see if they will cover your copay. Always use medicare site first. You have to sign up by Dec 7 for your new plan. Your doctor can request coverage for non plan drugs from insurance company

[dhccpa in reply to Murk]

See Laun's comment below about that.

[Murk in reply to dhccpa]

I'll look into it thanks. I was all over even talked and couldn't get an answer for Orgovyx which is a tier 5 drug. The pricing I got made no sense so thanks again and will reverse engineer what happened.

[Godfather2]

I’m about to start radiation treatment for prostate cancer and my doctor recommended two injections of Lupron lasting six months.

Thanks to this forum I started researching Orgovyx as an alternative. I was impressed by reports that showed fewer side effects and quicker testosterone recovery after using the drug. I emailed my doctor to see if Orgovyx would be a good alternative and gave him a link to a study showing good results for Orgovyx. His staff replied that Lupron was the standard procedure and that there were problems getting insurance to cover Orgovyx. When the day arrived for the Lupron shot I again asked about Orgovyx and asked the doctor to see if my insurance would cover it. He had examined the literature on Orgovyx and was impressed. He checked my BCBS Medicare Advantage plan and found that I needed pre approval but they would cover it with a $56 a month copay. And they would deliver the prescription to my house free of charge!

I opted for Orgovyx, got approval the same day and started the drug the next day.

I think the medical community is starting to recognize the value of Orgovyx and the insurance companies are beginning to appreciate the value as well.

[Murk]

Heya Dale and let me answer your questions…

1) I was on Orgovyx for just short of six months due to timing of events mentioned above.

2) I didn’t and won’t hit the $3300 drug ceiling costs since no other meds prescribed, I am anti-drug and pro organic remedies unless its essential to wellbeing etc.

3) My Doc (Sean Collins – Georgetown) strongly recommends Orgovyx over anything else currently on the market due to effectiveness, lower side effects and quick recovery time.

4) He reviewed my currently health status, records from my GP, as well as the after reports from my RP. I have no heart disease issues.

5) Since I had a RP with no margins etc, I was a candidate for short term, six months of ADT

6) He did not mention that there are no long-term studies comparing disease outcomes when Orgovyx is used vs injectables.

7) For more ammo I would schedule a second opinion with a highly rated doctor at a stellar facility. My Doc’s can practice in DC, Virginia, Maryland, Pennsylvania if you are located in any? If not ask in forum for some help and recommendations and go get another opinion from the best.

8) IMO, Kaiser will want to keep you in network and keep costs down. That’s why OCO360 offers a free trial 30-day supply. They have found that lots of times insurance companies will rescind their NO WON”T COVER decision once the Doc asks a second time and that you have started the first 30-day treatment…,

[maley2711]

Thanks Murk ! I see that you had ADT with salvage RT....thus would be classified as part of treatment for recurrence. The FDA approval was actually for advanced/recurrent PCa, and no mention of Orgovyx use for initial "curative" RT. So, your argument for using it would be much stronger it seems.

As for Kaiser, all insurance systems want to keep costs down...apparently without much success, as US is biggest per capita spender on medical in world...17% of GDP, whereas other developed countries are closer to 10-11% per my reading. Like everything in life, Kaiser has its pluses and minuses...the big minus is restriction on covered Docs, of course. Case by case, they will cover outside Docs......if there is a specialty for which they are not properly staffed. Kaiser did approve MRI before biopsy, and even now that is NOT SOC in USA. Our Kaiser currently doesn't have a brachy specialist, but my new RO has sent men to a Cal. Kaiser specialist....which kinda sucks, since there are at least 2 non-Kaiser brachy Docs here!! I wouldhave appealed and asked for the brachy with one of them, and covered by Kaiser.

Kaiser is also the world-best when it comes to medical records......seamless use by all Kaiser Docs in all specialties. My sister is in traditional Medicare, and she has been very frustrated when needing to move records from one Doc to another!!

I'm torn on deciding to stay with Kaiser Medicare Advantage or move to traditional Medicare with supplements...especially concerned aboutlack of selection for PartD with Kaiser Advantage.....they may be allowed to have a higher max, eg $8000?, for out of pocket drugs??? I'm unlikely to think it is worth it to travel hundreds/thousands of miles for "better" treatment someplace other than Portland. And I have no way to know if Doc s in other local clinics are really any better??? Having cancer, if I start with Medicare Advantage, it i unlikely that I would later be approved by any supplement company, should I wish to change to traditional Medicare with supplement, If I start with supplement, evidently there are no pre-existing conditions worries if I later decide to switch to an Advantage plan, Kaiser or any other plan.

My wife is just now retiring, so we are losing her Kaiser employee coverage, which is basically zero cost for anything...and zero premiums....in other words, Cadillac coverage...including dental and vision!!

I feel somewhat overwhelmed..deciding on any potentially life-changing treatment and the insurance decision at the very same time. I am also high risk...Gleason 4+5 for 3 years or more with no treatment......PSA a month ago had risen to 12.8 from 7.5 three years ago......new PSMA PET(2nd for me at Kaiser) still clean, cept some additional uptake in the prostate.

If I knew I'd have no worse SEs than you have had, the decison wouuld be easier...and also easier with 6 mo of ADT, versus the 18 months Kaiser wants!! Then again, metastatic cancer sucks!!! I can't convince myself to go the surgery route.....maybe I'm foolish, being told I'm a "good candidate" for robotic RP.

All I can do I guess is give my RO some example of other men who have used Orgovyx with RT, and there are 2 retrospective studies of men who had either Orgovyx or Lupron for RT treatment...the observation time after treatment is not long enuf to detect differences in cancer control between the 2 groups, but so far the recurrence rate betwennthe 2 groups is almost identical. I can also preent studies showing the shorter T recovery time for men who have used Orgovyx....for many men(me?) that would bemore important even if use Of Orgovyx ultimately results in slightly less effective cancer control...ie higher PCa mortality rate.

Finally, like my urologist, I am a coward, and hate injections of any sort!

Thanks for your help Murk!!