Why do Medicare Rx Plans exclude Viagra??

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Paella
Regular Member


Date Joined May 2010
Total Posts : 52
   Posted 6/12/2010 11:32 AM (GMT -6)   

Why do most Medicare Prescription Drug Plans exclude any coverage for Viagra?

I can understand that it wouldn't be covered for "recreational" use (if there is such a thing) but since it is an integral part of prostate cancer therapy, ZERO coverage just doesn't make sense.  

Does anyone's insurance cover this?

ths - Paella


logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 6084
   Posted 6/12/2010 12:40 PM (GMT -6)   
Mine, HMSA, a Hawaii ins afiliate BCBS, will give you 12 for 68 days thru MEDCO,google, most seem to give u that, at least. 80$
age 66 First psa 4/17/09 psa 8.3, 7/27/09 psa 8.1
8/12/09 biopsy 6 out of 12 pos 2-70%, rest <5% 3+3
10/19/09 open rrp U of W Medical Center, left bundle spared
10/30/09 catheter out. continent from the jump.
pathology- prostate confined, only thing positive was the report.everything else negative
9% of prostate affected. gleason 3+4, I suppose thats a negative
After reading pathology myself, gleason was 3+4 with tertiary 5, 2-3 foci That is a negative, but I am a positive !!
Ed an issue but keeping the blood flowing with the osbon pump
Dec 14,2009 psa 0.0 May 10 2010, psa 0.0

" Hypocrisy is vice's homage to Virtue " read it in Bartlet's book of quotation years ago stuck with me, can't remember who said it.


James C.
Veteran Member


Date Joined Aug 2007
Total Posts : 4463
   Posted 6/12/2010 1:24 PM (GMT -6)   
Hmm, I just checked my online Medco Plan- available as part of my retirement benfits- with Cigna as the health provider, and it tells me I can get a 90 days supply of 100mg Viagra or 20 mg Cialis- a total of 18 pills- for $70.00 out of pocket, with the plan paying 271.34. That's using their mail service. That must be something new, as it didn't pay 3 years ago when I first asked. That's one each 5 days, not bad for the Cialis to keep a steady blood stream count for the longest time available.
James C. Age 63
Gonna Make Myself A Better Man www.youtube.com/watch?v=a6cX61oNsRQ&feature=channel
4/07: PSA 7.6, Recheck after 4 weeks Cipro-6.7
7/07 Biopsy: 3 of 16 PCa, 5% invloved, left lobe, GS3+3=6
9/07: Nerve Sparing open RRP, 110gms, Path Report- Stg. pT2c, 110 gms., margins clear
3 Years: PSA's .04 each test since surgery, ED continues: Bimix- .3ml PRN, Trimix- .15ml PRN


geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 6/12/2010 3:49 PM (GMT -6)   
I think the problem with ED drugs for penile rehabilitation is that it is not a "proven" treatment supported by appropriate clinical studies. The docs that favor it do so because of their own opinions and experience which is, in general, not enough for insurance companies.
Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3+4=7
CAT scan, Bone scan 1/09 both negative.

Robotic surgery 03/03/09 Catheter Out 03/08/09
Pathology: Lymph nodes & Seminal vesicles negative
Margins positive, Capsular penetration extensive Gleason 4+3=7
6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.
10 weeks: no pad at night -- slight leakage day/1 pad.
3 mo. PSA 0.0 - now light pads
6 mo. PSA 0.00 -- 1 light pad/day
9 mo. PSA 0.00 -- 1 light pad/day ED remains
12 mo. PSA 0.00 -- still one light pad and ED


RCS
Veteran Member


Date Joined Dec 2009
Total Posts : 1268
   Posted 6/12/2010 4:16 PM (GMT -6)   
Paelle,

My Kaiser insurance does not cover it; However, my Tricare does ... 18 pills every three months ($22 for 18).
PSA 2007 - 2.8
PSA 11/24/2008 - 7.6
Pc Dx 2/11/09; age at Dx 62
RLP 4/20/09
Biopsy -  Invasive moderately differentiated prostatic andenocarconoma; G 3+3=6; PT2C; No evidence of Seminal Vesicle or Extraprostatic Involvement; Margins clear; Tumor identified in sections from prostatic apex.
70 gram prostate.
Immediately continent after removal of cath.
ED - Trimix works well; viagra @ 60%
PSA - 7/31/09 <0.06
PSA - 12/1/09 <0.06
PSA - 3/29/10 <0.06
 
 
 


Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 6/12/2010 4:18 PM (GMT -6)   
Paella,  Congress specifically prohibited Medicare Part D plans from paying for ED drugs.  This is the wording from my Part D insurer; " By law, this drug is excluded from being covered under the Medicare program. Certain plans, including this one, cover this drug as a supplemental benefit to their plan. However, any amount you spend for this drug is not counted toward any deductibles, initial coverage or out-of-pocket limits".  This particular plan has a $60/mo. premium and a large decutible.  Most of the lower cost plans do not have any coverage.  My employee retiree plan covered ED drugs but I was forced to change to Medicare once the Part D plan became available.  If memory serves me right,  Congress did not exlude themselves from ED drugs.
 
Carlos

Diagnosed 2/2008 at age 71, Gleason score 5+3=8, stage T1c, PSA 9.1. 
Robotic surgery 5/2008, nerves spared, stg. pT2c, N0, MX, R0, Gleason 5+3=8 
PSA <0.1 at 20 months and each test since surgery.


Paella
Regular Member


Date Joined May 2010
Total Posts : 52
   Posted 6/12/2010 5:14 PM (GMT -6)   
Then I think AARP ought to make itself useful and start lobbying for this. They don't have to PAY for the drug but with a prescription it certainly should be available to its insurance members at the gigantic bulk rate that AARP surely could get.

Paella

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 6/12/2010 7:14 PM (GMT -6)   
Paella,  AARP has 3 different Part D plans available.  The best AARP can do on 50 mg viagra is $172.99 for 10 pills.  If you are interested in Part D info, just go to the Medicare.gov site and check out the different plans.  I think that Coventry with Medco had much better prices.

Diagnosed 2/2008 at age 71, Gleason score 5+3=8, stage T1c, PSA 9.1. 
Robotic surgery 5/2008, nerves spared, stg. pT2c, N0, MX, R0, Gleason 5+3=8 
PSA <0.1 at 20 months and each test since surgery.


Paella
Regular Member


Date Joined May 2010
Total Posts : 52
   Posted 6/12/2010 7:34 PM (GMT -6)   
Carlos - I checked that last night and apparently our county/zip/whatever doesn't have any AARP Rx plans that offer any price on V. We have 3 available plans, too - but all say that it is "excluded". Maybe I need to try that search one more time...I bet I entered something wrong.

Oh well. I think I just need something to vent about with Mac's surgery in 50 hours.

(And, of course, Congress didn't exlude themselves from ED drugs.)

Paella

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 6/12/2010 7:49 PM (GMT -6)   
Paella,  You are correct when you say that ED drugs are excluded.  But, if you click on the details or compare several plans,  it should show the AARP negotiated retail price that you pay when you use your local pharmacy.   Good luck to you and Mack with his upcoming surgery. 
 
Carlos

Diagnosed 2/2008 at age 71, Gleason score 5+3=8, stage T1c, PSA 9.1. 
Robotic surgery 5/2008, nerves spared, stg. pT2c, N0, MX, R0, Gleason 5+3=8 
PSA <0.1 at 20 months and each test since surgery.


pogmothoin
Regular Member


Date Joined May 2010
Total Posts : 84
   Posted 6/12/2010 8:03 PM (GMT -6)   
My private insurance won't pay for it, and my pharmacist says he has essentially never seen that happen.

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2692
   Posted 6/12/2010 9:08 PM (GMT -6)   
Be sure and check out adc, and Indian manufacturer of an equvalent. Many men on here use it, for less than a $1 a 100MG pill. Called Manly.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01


MrGimpy
Veteran Member


Date Joined Jul 2009
Total Posts : 504
   Posted 6/14/2010 5:02 AM (GMT -6)   
Hi Paella

You Wrote
" but since it is an integral part of prostate cancer therapy, ZERO coverage just doesn't make sense. "

Can you post where you read that Viagra helps prevent Prosatate cancer or helps in preventing its return. If you can then you have a good argument for your Ins Company
Stats:
Age: 52, PSA (2008)=1.9
Biopsy on 01/09/09, Gleason Score = 3+3
One (1) out of twelve (12) cores was positive, plus external nodule found
Surgery (Da Vinci, robotic prostatectomy): 4/7/09
Post Op Path 3+3
Removed Catheter: 04/19/09
100% bladder control - Pad free 7/09
PSA 7/09 undetectable, <0.01 - 3 months post-op
PSA 1/10 undetectable, <0.01 - 9 months post-op
Trimix provides 100% erectile function


BobCape
Regular Member


Date Joined Jun 2010
Total Posts : 416
   Posted 6/14/2010 6:42 AM (GMT -6)   
Mr. Gimpy, part of prostate cancer therapy is helping the man regain some semblance of a normal life. Since without erections neither I NOR YOUR would likely be born, I would suggest there is SOME importance for a man to be able to have sexual function.
First ever PSA test Jan 2010 @ 51 years old. 4.0.
Digital exam in March 2010 showed 1 side hard, other soft.
Biopsy, positive in 3 of 12.
Davinci @ Boston Medical Center, May 17, 2010.
Was suggested prior to it was likely contained.
June 1 advised 3+-4 was really 4+3 per pathology. Pos margins.
Catheter removed June 1.. 1 pad/day, doing ok. ED, but not in rush.
Sore as heck down there, but doing much walking with my wife.
To meet with my Uri (1st meeting since) June 17 - 1 mo point, to discuss.
BMC already has me setup to meet with radiology.
Felling a little better each day. Cant tell if my expectancy just went from 10-15 down to 5-7, the information out there appears to be all over the place. I WILL NOT radiate my insides to the point of being a veg for the sake of a few years. QOL is primary to me. Selfish I guess. I pray for all of you as I do for myself, but must remember that i've had a pretty good 50+ years, and know others who have lost their children to disease.. so I dont have the nerve to complain!


Sephie
Veteran Member


Date Joined Jun 2008
Total Posts : 1804
   Posted 6/14/2010 7:19 AM (GMT -6)   
Our insurance pays for four 100 mg. pills every 30 days with an out-of-pocket cost of $30.00. John has started ordering Viagra through All Day Chemist (its called Manly).

While ED medication cannot be considered part of prostate cancer therapy per se, it is prescribed for "penile rehabilitation" to help in the healing process after surgery. Increased blood flow to the area promotes quicker healing hence the "rehabilitation." Insurance companies, including Medicare, still see ED drugs as "recreational" and don't recognize its use as a therapeutic.
Husband diagnosed in 2/2008 at age 57 with stage T1c. Robotic surgery performed 3/2008. Stage upgraded to T3a (solitary focus of extraprostatic extension). Perineural tumor infiltration present. Apex margin, bladder neck and SVs negative. Final Gleason 3+4. PSA: 0.0 til July 2009. August 2009 - 0.1, September 0.3, October back to 0.0, December 0.0, March 2010 0.0. Next PSA in 6 months. Thank you God!


MrGimpy
Veteran Member


Date Joined Jul 2009
Total Posts : 504
   Posted 6/14/2010 8:29 AM (GMT -6)   
Bob,

Plenty of arguments that one can live a perfectly normal life without a Viagra assisted erection

As for fathering a child, well once your prostate is removed, Viagra is not going to help you there either so if our dads had PC and their ins company did pay for Viagra well we are still not here

A great natural blood flow stimulator that helps in ED recovery is L-Arginine, no script needed just eat a handful of walnuts a day

But I agree that ED drugs should be covered as PC is not a normal need for the drug and in the early stages nocturnal erections are needed and not for recreation purposes

What is odd is that Bimix or Trimix is also not covered by Ins companies but the syringes are, go figure
Stats:
Age: 52, PSA (2008)=1.9
Biopsy on 01/09/09, Gleason Score = 3+3
One (1) out of twelve (12) cores was positive, plus external nodule found
Surgery (Da Vinci, robotic prostatectomy): 4/7/09
Post Op Path 3+3
Removed Catheter: 04/19/09
100% bladder control - Pad free 7/09
PSA 7/09 undetectable, <0.01 - 3 months post-op
PSA 1/10 undetectable, <0.01 - 9 months post-op
Trimix provides 100% erectile function


bsjoplin
Regular Member


Date Joined Feb 2010
Total Posts : 308
   Posted 6/14/2010 1:33 PM (GMT -6)   
just to add another person's experience, my company's insurance plan specifically will NOT cover the ED drugs, but i got a waver while i am in this "rehabilitation" stage, and they are paying very well.  i'm sure when this phase is over, the drugs will again NOT be covered, but hopefully (probable, but no certainty!) i will be back to something close to normal, and not require them...
bob

Age@dx: 55

5/05             PSA test 1.8  --12/19/07  PSA test 3.7  --7/25/08    PSA test: 4.7

8/26/08        1st Prostate Biopsy: 3 samples out of 6 have irregular cells

11/25/08      PSA test: 6.5

12/11/08      2nd Prostate Biopsy :  of 12 samples, 3 are cancer, and all other 9 are irregular.  original NJ lab sent samples to Johns Hopkins for special reading.  Gleason 3+3=6.  now:read book, and think about options: radiation, surgery, etc

1/22/09        Radical Retropubic Prostatectomy.  main issue was use of BOTH pre-donated units of blood during surgery, and then required 2 additional units in recovery, before going to room

1/25/09        Released from hospital. No drive, no lift >5 lb

1/28/09        Pathology results from removed tissue:  Cancer was seen on 10% of gland, lymph nodes & SV were benign, nothing seen outside of the prostate.  One area of cancer extended right up to edge, but not beyond.  Gleason was re-typed as 3+4=7, staged T2c

2/13/09        PSA=0.1

3/6/09          6week appt, start back to work Monday, 3/9.  script for Cialis

6/8/09          PSA=0.1

10/9/09        PSA=0.1

2/10/10        PSA=0.3 discussed possibility of radiotherapy and/or hormone.

4/7/10          PSA= 0.4  Recurrence of the cancer is probable. Referred me to RO

5/4/10                   First RT.  RO is recommending 37 treatments x 1.8Gy=66.6 Gy

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