79 replies to this topic

[LAC1223]

Just this weekend I received a letter from CVS Caremark indicating that 'they have denied my doctor's authorization for a new script for Sprycel as the Current Plan approved criteria does not allow coverage of Sprycel if the chronic myeloid leukemia cells are note Philadelphia chromosome positive and/or BCR-ABL positive.'  But... 'you can choose to receive the medicine at your own expense'.  In the middle of trying to figure this all out - waiting for my doctor's office to call me back.  After dealing with the side effects and being told I needed to stay on it for the indefinite future as my doctor didn't feel there was sufficient support to take me off, I finally reconciled myself to just dealing with the side effects as the alternative could be way worse.  Now this.  As if the diagnosis of CML and the medicine weren't enough of an emotional roller coaster, insurance needs to stir the mix.  I have CDPHP, but scripts are thru CVS Caremark.  I can switch over to MVP for 2017 - but I am told CVS Caremark (who sent me the letter about no coverage for Sprycel) manages scripts for them too.  My head is spinning. 

 

Has anyone else had an issues with Insurance?

[r06ue1]

I am also with CVS Caremark but still on Gleevec (I had my doctor rewrite the prescription to keep me on the brand name).  I have not heard of this but it sounds very peculiar.  You had prior authorization for Sprycel before the letter correct?  If your doctor requests that prescription than I believe they have to fulfill it.  

 

It sounds like CVS Caremark is trying to force people onto generic imatinib which was a concern of mine after it was released.  Legally, I don't know if there is anything protecting us from being forced onto another medicine which is considered "equivalent".  Scary.

[rcase13]

Yes, CVS Specialty will be removing both Gleevec and Tasigna from their formulary.

 

http://investors.cvs...and-updates.pdf

 

I am on Tasigna. I guess we will get moved to one of the other drugs? Can i assume generic Gleevec will be included?

[r06ue1]

But they make no mention of Sprycel, which is why I think this might be a mistake, unless they are now trying to move everyone to generic imatinib.

[LAC1223]

Interesting - thanks for the link.  And it doesn't mention Sprycel, just the Gleevac and Tasigna - still no word back from my doctor who said they would contact CVS Caremark find out what was going on and call me back.  And oddly enough, they did not even mention the generic in my letter at all - just that they were no longer covering my Sprycel, mentioned my levels were the equivalent to 'remission' in one section.

[LAC1223]

And my authorization for 100 mg of Sprycel has been ongoing since July of 2011 - I've never been on anything else.

[r06ue1]

So the insurance companies are now determining who goes on the stop trials?  I guess that is one way to save money and fatten the bottom line.  

[LAC1223]

So the insurance companies are now determining who goes on the stop trials?  I guess that is one way to save money and fatten the bottom line.  

I guess so - still waiting on the doctor's office to call me since I spoke with them yesterday.  If I don't hear from them by end of day today, I will give them a call tomorrow.  I'm just glad I had one 3 month refill left to give me enough time to try to get this worked out, or not - maybe this is a sign I was meant to be on a stop trial 

[Buzzm1]

At this moment in time, it isn't as if the insurance companies are going to save a great deal of money by switching CML patients over to generic Imatinib/Gleevec; the generic is priced right up there with the patented TKI's.

 

Silvertabby, on 10 Sept 2016 - 9:43 PM, said:

Buzz,

June, 2016 Gleevec (Novartis). Walgreen's Specialty billed amount: $12,146.92. Premera BCBS paid $9,851.15
July, 2016 Imatinib (Sun Pharm). Walgreen's Specialty billed amount: $11,839.77. Premera BCBS paid $9.602.05
August, 2016 Imatinib (Apotex Corp). Walgreen's Specialty billed amount: $11,839.77. Premera BCBS paid $9,602.05

After almost 3 years, I received my second PCRU result. The first one was last December. The next two were .015 and .024. I am praying the cost will come down substantially very soon. I feel like I am single-handedly bankrupting Premera. I do not like depending on others to pay for my meds.

Silvertabby, thank you very much for that information ... the July Sun and August Apotex prices, being exactly the same, show collusion between Sun and Apotex on the price of generic Imatinib ... 

 

Assuming that the prices shown are for 30 X 400mg, the generic price of $11,839.77 calculates out to $144,050/yr.

 

I'm a little confused at this point because the price I obtained a few weeks ago from Kaiser for Novartis Gleevec 30 X 400mg was $11,371 which calculates out to $138,347/yr. ... the $12,146.92 that you were charged in June calculates out to $147,788/yr.

 

Glad to hear that you have hit PCRU ... it's not unusual to bounce in and out of PCRU at first .. did the same thing myself ... Good Luck to you and thanks again for the pricing information.   I hate the thought of the greedy Big PhRMA companies raking us over the coals ... 

[jrb666]

I have been on Tasigna since my diagnosis 2 years ago.

 

I recently changed jobs. I have BCBS of Texas, and the pharmacy provider is CVS Caremark.

 

When I tried to fill my Rx it was initially denied. I was told that they would only approve Sprycel or Bosulif. My doctor had to go through some kind of authorization process and I eventually got my Tasigna after two weeks of phone calls, emails, whining, kicking, screaming, etc.

 

At my former job, CVS Caremark was also the pharmacy, and there was none of the BS. CVS Caremark already had my records, authorizations from my doctor, etc. so I don't know why they needed a new authorization. It must be that the insurance company, not CVS Caremark is calling the shots.

 

Also, at my prior  job, I got 3 months of medication at a time. Now I have to refill every 28 days. Every month I will receive a giant box full of ice-packs surrounding a one month supply of pills, delivered via next-day air. It seems so wasteful.

 

I understand why the insurance companies want to push back on the Pharma companies, but it sucks for those of us who depend on these meds to stay alive!

[beno]

 

At this moment in time, it isn't as if the insurance companies are going to save a great deal of money by switching CML patients over to generic Imatinib/Gleevec; the generic is priced right up there with the patented TKI's.

 

 

This isn't necessarily true.  The generic can have one list price, but CVS Caremark may have negotiated a much lower price with a manufacturer.  To get this much lower price, generally they will agree to put incentives to try to switch users to the preferred medicine and manufacturer.  And much lower in some cases can be more than 90% below list price an individual would be forced to pay.

[chriskuo]

The PBM pharmacy benefits manager cuts deals with both the insurance company (which may own it), the employer, and the manufacturer.  This is a big black box of discounts and rebates.  (See the congressional hearings on Epipen today and then multiply the amounts by 100-200x.)

[r06ue1]

Wouldn't it be interesting to find out in the future that Insurance companies were using inflated drug prices from the manufacturers (which the insurance companies were never actually paying) as the reason for hiking insurance prices (or raising deductibles, co-pays, etc...) just so that they could fatten their bottom lines?

[rcase13]

I finally got my Tasigna renewal worked out. I was unable to get CVS Specialty Pharmacy to send it. Both my doctor and I tried several times. We rain into brick walls every time. It is strange because I have been getting it from them for two years. I instead got it from my Cancer center's pharmacy and had no issue. They even called Novartis and renewed my prescription assistance card for me. I got my Tasigna and it didn't cost me a dime.

 

So in my case the problem wasn't the CVS Caremark prescription insurance it was the CVS Specialty Pharmacy that Caremark uses.

[jrb666]

I'm so confused. I don't understand the relationship between the insurance company and CVS specialty pharmacy. Who does the pharmacy benefits manager officially work for? Who makes the ultimate decision?

 

rcase13: Why was the cancer center able to fill the prescription, but CVS Specialty Pharmacy would not?. Doesn't your insurance company require you to use CVS specialty? (apparently not!). At some point the meds need to be paid for.

 

LAC1223: It seems odd that you were denied Sprycel. I was denied Tasigna, but told that Sprycel would be approved. Also seems odd that the reason you were denied was because you were not Philadelphia chromosome positive and/or BCR-ABL positive. Well of course you weren't!! That's because the Sprycel is working!!

 

Call me paranoid, but it seems that the strategy is to make it so difficult to get the drugs that we will give up and go without, as if that were an option.

[rcase13]

I have no clue why CVS Specialty Pharmacy was being so difficult and completely unwilling to work with me. If you have CareMark you are NOT required to use CVS Specialty.

Talking with my wife about it, we think they are are just too big to respond with any empathy. They read scripts and if something is outside those scripts they shutdown.

I am just thrilled with the cancer center I go to. The doctor, nurse and pharmacy managers there go above and beyond time and time again. I about dropped dead when the pharmacy called Novartis for me to clear up an issue with the assistance card.

[beno]

I get my Sprycel through the pharmacy at my hospital (Univ. of Iowa) and they are great also.  I live 70 miles away.  They call me when I have about 1 week supply remaining and mail it to me for no extra charge.  I haven't gotten service like that from any chain pharmacy.

 

And speaking of chain pharmacies, I normally fill all my other prescriptions at the local CVS, but I'm switching to Walgreens in solidarity with the people struggling with CVS Caremark approving their meds.

[rcase13]

Agreed I won't be doing any more business with CVS.

[LAC1223]

Latest news - still waiting.  Called CVS Caremark as I noticed my co-pay spiked the last time I paid and they told me that the price on Sprycel has gone up three-fold since last year - it would cost me $71,735 for a three month supply if I didn't have insurance (YIKES), so it is the pharmaceutical company that is the main problem.  My Doctor's office called and said they are sending a letter as I am STILL ( BCR/ABL positive which the letter indicates CVS Caremark would still cover me.  On top of this, work has notified me (letter came yesterday) that CVS Caremark will be managing this until the end of the year and then OptumRX which uses BriovaRX for their Speciality scripts will be the new administrator in 2017,  Don't know if I should laugh or cry - so I'm spilling to all of you 

[LAC1223]

They are all nuts and they are trying to drive me crazy with them!