Insurance help for perjeta

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sandj
sandj Member Posts: 27
edited October 2016 in Stage IV/Metastatic Breast Cancer ONLY

Hi everyone,

I was originally diagnosed in 2012 while pregnant with Her2+, ER/PR negative metastatic disease. I had a 1cm liver met and sternal metastases. Initially took FAC and then after my baby was born I was given abraxane/herceptin/perjeta and got to NED. I stopped abraxane and had surgery- mastectomy, complete axillary dissection and liver resection. I had a complete pathological response and remained NED while staying on herceptin and perjeta every 3 weeks. I also had radiation to the chest and sternum. BCBS is now saying that it is not medically necessary and does not want to continue to pay for the perjeta. I am 3 years NED and I am terrified about having to stop the perjeta. Has anyone else run into this problem? Does anyone have a different plan that has continued to pay long term without problems? Any suggestions regarding appealing? Thank you so much!

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  • Fitztwins
    Fitztwins Member Posts: 7,969
    edited October 2016

    Where do you live? any chance in Michigan.( I know someone). Maybe getting a patient advocate to fight for you. If your doctor feels its medically necessary. I think prejeta is recommend at least 5 years. It really isn't that hard to fight for life savings drugs.

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  • sandj
    sandj Member Posts: 27
    edited October 2016

    I live in Texas. Thanks, I will be working on it

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  • Moderators
    Moderators Member Posts: 25,912
    edited October 2016

    Hi Sandj,

    In addition, from the main Breastcancer.org site's page on Tips to Lower Medicine Costs in the Paying for Your Care section:

    Genentech, which makes Perjeta (chemical name: pertuzumab), offers Access Solutions. Call 1-866-4-ACCESS (1-866-422-2377) for more information.

    We hope this helps!

    --The Mods


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  • Beatmon
    Beatmon Member Posts: 1,562
    edited October 2016

    I don't understand how the insurance can regulate your need for Perjeta! Sternal mets and a liver resection don't get you a ticket for that?

    Now I question how long have people been on both? I know Perjeta has only been available to give with the Herceptin for a few years.

    Does anyone know. I'm going to post this question on the H&P thread.

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  • sandj
    sandj Member Posts: 27
    edited October 2016

    People have not been on both for long. Pertuzumab got FDA approval in summer of 2012z I have been on it since April 2013, initially with chemo. Given that stage 4 is considered incurable, we think the combination is keeping the cancer at bay.

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  • Cafelovr
    Cafelovr Member Posts: 1,534
    edited October 2016

    BCBS has paid for all of my chemos, including almost 7 years of Herceptin. I've never had Perjeta, and have been NED since May, 2010. I hate when Big Pharma and Insurance companies try to play doctors! I've wondered if I'll ever "max out"...

    Good luck!

    Linda

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  • RonnieKay
    RonnieKay Member Posts: 2,067
    edited October 2016

    When I was dx w/extensive liver mets, 12/12, my onc wanted navelbine, xeloda & herceptin (I'd had tax, cytoxan & herceptin in '09). Luckily (I think), my ins denied xeloda, saying it hadn't been used w/navelbine in enough studies, so my onc reached for perjeta in its place. I was on all 3 for 22 months, when onc dropped chemo, and then dropped perjeta after 30 months. It had nothing to do with ins, but more to do with ses & the thought that herceptin could do it alone. I was super scared too...but relieved to try going without. That was 7/15...and still going strong. I'm er/pr + and I think that may be why herceptin may be the main ticket??? Anyhoo....good luck....is your onc nervous a bout dropping it

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  • pwilmarth
    pwilmarth Member Posts: 235
    edited October 2016

    This is straight up an insurance game to avoid paying for Perjeta. There is no data that supports stopping Perjeta once you're NED. There is no data that support stopping Perjeta after 5 years.

    The current standard of care for first-line metastatic disease is Taxotere, Herceptin, and Perjeta. Some oncologists have chosen to use Abraxane or Navalbine instead of Taxotere and there are studies that support that use.

    Most of the organizations in the US that determine the standards of care for HER2+ breast cancer have taken this stance. Most of the oncologists who have been involved in the research around Herceptin and Perjeta believe that it is important to follow the protocol as it was developed under the Cleopatra studies.

    This kind of thinking by the insurance companies ticks me off. I was NED on H&P for 18 months and just recently progressed. The Cleopatra studies found a median Progression-Free survival rate of 19 months. Which means that some women will progress after the 19 month window. Imagine if I had an insurance company that determined I didn't need those extra months of NED that Perjeta gave me?

    Personally, I would look at the appeals process for your insurance company and fight this.

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