Does anyone know about a list of oncology medications and treatments per prognosis that are followed by Oncologists/Insurances in the US?
In trying to get approved for a new medication after progression of my metastasis, I was denied. Apparently it didn't follow the 'protocol' that is set forth by (?? A cancer treatment organization??) so that insurances will know if the medication/treatment prescribed by our Oncologist follows the set of 'rules/guidelines' put forth by said organization.
Is anyone of aware of this protocol/guidelines? My efforts online have been fruitless.
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SpicyChick
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What is the med for which you were seeking approval? I do know that insurance companies can be hamstrung by regulations, but your oncologist can go to bat with the drug companies to seek coverage and financing.
Hi Miss Spicy chick, most oncologist defer to NCCN guidelines in USA and ESMO guidelines in Europe. I do know some insurance companies try to encourage “patient pathways” where they look at similar drugs and encourage the value based choice where there are treatments available of similar efficacy … in some disease states, that may require failing on one treatment before being allowed to get the prior authorization for the more expensive drug. In oncology, the Drs sometimes need to write letters to insurance companies to get the best drug for their patient. I hope that was helpful but hard to know as I don’t know what drugs you are experiencing difficulties with. Wishing you smooth sailing!
(After mets progression on Ibrance/Letrozole, the Onc is trying to get Kisqali/Faslodex approved). I'm also trying to see if that is supposed to be a normal next line of defense, based on a letter I received from the insurance/medication department about my denial.
it may be that your onc is trying to get approval for another CDK med. Kisquali is the same class of drug as Ibrance. My onc said she doesn’t do that as there is currently no data to support success. I can’t imagine there aren’t studies about that course of treatment, just no data yet. So frustrating when insurance companies dictate treatment.
It’s probably the Kisqali that the insurance company is rejecting. It’s the most expensive one in its class. Since you failed in Ibrance, the insurance company probably doesn’t want to fund another inhibitor in the same class. Fulvestrant (Faslodex) is often the next line of treatment when an aromatase inhibitor (like letrozole) fails. The targeted therapies are optional. Targeted therapies are never administered alone and always need a hormone therapy to do all the heavy lifting. Fulvestrant is considered to be a more powerful hormone therapy than letrozole and patients often get more PFS out of it. I’ve been using fulvestrant alone after having a horrible experience with side effects on Kisqali. My onc was not concerned about dropping the Kisqali because the fulvestrant is what’s most important. I was told that six years ago, before all the targeted therapies became approved, fulvestrant alone was the standard of care as a second line treatment for ER+ HER2- type MBC. Fulvestrant has a generic and is not expensive. I doubt your insurance company would deny that one.
It seems like the denial is specific to your insurance: look at the responses of people who did go onto fulvestrant and Kisqali after the initial Rx failed.
I looked at the NCCN guidelines (for patients) for mbc (nccn.org/patients/guideline.... Chart 4 does indicate that the combo your doctor recommends, including Kisqali, is a good second line of treatment IF another CDK4/6 has not already failed. That must be what your insurance company is going by.
Nonetheless, many of us, including me, have gone to a second CDK4/6 after the first one ultimately stopped working. I believe it is what my onc calls "standard of care," even if not in the guidelines, to do that. My second opinion doc explained that the research is not there for all the combinations but anecdotally, it can work; my primary oncologist just said, we don't know why it works (to try a different CDK4/6 inhibitor, or targeted therapy), we just observe that it often does.
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