6 replies to this topic

[Johnc]

I responded slowly over 4 months with Gleevecs and Onc wrote script for Sprycel and insurance denied it and requested  mutation test first.

Has anyone experienced this?

How long does it take to get results back?

If I have the T135i mutation will they deny medication since Phontueb is not approved yet?

What percentage of folks have this mutations?

Any answers or thoughts would be helpful

Thanks,

Johnv

[Trey]

John,

Your insurance company has taken the inappropriate view that switching drugs can only occur in the presence of a kinase mutation.  That is inexcusable and you need to have you Onc tell them what idiots they are, which unfortunately takes time an Onc does not like to waste with them.  Ask the insurance company for a copy of their drug switch rules they are using.  Likely a gross misinterpretation.  Most drug failure and/or drug under-performance is not related to kinase mutations.

[Johnc]

Thanks Trey and Bcov

I am wondering if I should refuse and go straight to the insurance and not take the test or just  take the test? This is one of the largest insurance companies out there. Or could this be a start of the death panels??

Johnc

[Trey]

Another point is that Sprycel and Tasigna are now front-line drugs, even though they are sometimes called "second generation" drugs.  So they should never be denied if the Onc prescribes them.  See if the insurance company is confused about them being second line drugs only, as they were for several years, which in the old days meant Gleevec failure was required before the other drugs could be used.  Not any more.  I'll bet the insurance company approves Sprycel and Tasigna if the Onc prescribes either one for initial CML drug therapy. 

As for when the switch in drugs is appropriate, the Onc is the one who decides, not the insurance company.

http://asheducationb...2011/1/121.full

[Happycat]

It doesn't surprise me. Everyone wants to cut costs and they would probably rather keep patients on gleevec since that will go generic much sooner than sprycel.

That said, it should not be their choice. Should be based on what is appropriate and necessary to treat the patient.

I would not recommend taking the mutation test, since you need a LOT of the mutated version to show up as a positive. Don't give them any more information on which to deny it. Talk to your oncologist first, and let the onc deal with it.

HTH,

Traci

[haburke]

I just had a BMT and am no longer in need of my Tasigna.  I have a 3 week supply of 150 mg pills.  They expire next month, so I'd like to get them to someone ASAP.  They'd be great for a buffer supply - you can save your current prescription for the future in case you run into trouble with insurance or the pharmacy.

Please just let me know and I'll mail them out today or tomorrow.  You can contact me at hannaheburke@gmail.com

[Johnc]

-All-

Here is a quick update to my situation

I spent approximately 1 hour on the phone Monday with the Pharmacy and it was explained in no uncertain terms that my plan for this medication has the blood test under this medication. They would not provide the documentation unless the test came back positive where a resolution process would begin. I did in my opinion make sure this was just not a doctor making this call and that it was policy. As far as cutting cost, I see what they are doing, if they are to spend >$75k, then why would they wantto pay for something that won't work.

I went to the lab on Monday while giving up some blood for this test and the nurse came over from the Oncs office and a discussion ensued and they say this happens often in the world of cancer. Some folks may not even be aware of it.

A good friend of mine is a recently retired HR Director  at the same company I am at which is one of  top 25 companies in the country and he also has cancer and had to go through a similiar situation.

It is very unnerving but the Nurse said based on the Onc thoughts he said there is a slim chance I have the T 351i gene. Not sure exactly how he came to that conclusion but made the statement to his nurse. I don't think any doctor should speculate but he must know something based in my previous  test.

Be aware as I asked for the test sheet at lab that insurance company sent, it says "this test may not accurately detect mutations if present in fewer than 5%of CML cells"  This may explain why this mutant gene can go undetected for some time and rear it's guy head later on down the road.

I will find out tomorrow the results.

Jonc