Insurance denied Viagra use

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GregM
New Member


Date Joined May 2007
Total Posts : 3
   Posted 5/21/2007 3:56 PM (GMT -7)   
I had robotic surgery on May 4.  As part of the penile rehabiliation, I received a prescription for Viagra, 50mg every day.  My insurance (Blue Cross Blue Shield of NJ) has denied my request for medical necessity.  Nomal plan only allows four pills per month.  Use of Viagra or other ED drugs "in erectile rehabilitions after prostatectomy is considered investigaional."
 
I suspect this is just the company line.  Has anybody been successful appealing a denial for such medicine?  Also, does anybody have a plan that provides coverage?
 
Good news, cancer was contained in prostate.  I'm 53.

Izzyblizzy
Regular Member


Date Joined Oct 2006
Total Posts : 411
   Posted 5/21/2007 4:21 PM (GMT -7)   
Hi greg,

Welcome to the forum! Hope you are recovering well from your sugery!

I have heard a lot about people getting denied those. I think some people on here get them online? Hopefully someone will come along and get you the site. Our insurance luckily covers ours.

We have UnitedHealthcare in Colorado. (can't remember exact plan name off top of head, but can look it up if interested).

Ken gets 30 viagra and 20 Cialis for $20 for each prescription.

Tanya
Age: 63
Diagnosed: 10/30/06
PSA: 3.7 (2005: 3.4, 2004: 4.0)
Biopsy: 1/10 cancerous, 5% of one core, right apex.
Gleason: 3+3=6
Da Vinci: April 10, 2007, Denver CO
Path results: 1% of prostate involved. Very small tumors on both right and left apex. Negative margins, negative seminal vessicles, lymph nodes left intact. Gleason upgraded 3+4=7.
1st PSA Results: May 11, 2007 <.01
 


CVK
Regular Member


Date Joined Apr 2007
Total Posts : 66
   Posted 5/21/2007 4:51 PM (GMT -7)   
Hi Greg,
Welcome to the forum. Our Blue Cross Rx Insurance has a rider not covering impotence drugs also. My sister-in-law is a nurse and she said it should be covered for medical necessity. I called Blue Cross and pressed the issue but they wouldn't budge. We too are looking for a solution to this.
Age 52
Diagnosed 2/19/07
10 of 24 cores positive
Gleason 3+3=6 Changed to Gleason 7 after surgical pathology
PSA:3.3
DaVinci Prostatectomy May 11, 2007 at Univ. of Mich. Hospital
Stage: T2a
Pathology: May 16 - Cancer confined to prostate, Margins, Lymph & Seminal Vesicles all CLEAR!
Father and Uncle had prostate cancer


stkitt
Forum Moderator


Date Joined Apr 2007
Total Posts : 32602
   Posted 5/21/2007 5:45 PM (GMT -7)   

Hello Greg,

A warm welcome to the PCa forum. I am sorry you are having difficulty with your insurance. 

 

 


Respectfully
Kitt

Moderator Prostate Cancer
My Father and his 5 siblings all died of Cancer.
______________________________________________________
"If you doubt you can accomplish something, then you can’t accomplish it. You have to have confidence in your ability, and then be tough enough to follow through.” 
~Rosalyn Carter


Swimom
Veteran Member


Date Joined Apr 2006
Total Posts : 1732
   Posted 5/21/2007 6:17 PM (GMT -7)   
Greg,

alldaychemist.com is a place several peeps buy from. Tadalafil is not available from this site however, sildenafil and Tadalafil are. Good Luck to you.

Swim

pasayten
Regular Member


Date Joined Mar 2007
Total Posts : 424
   Posted 5/21/2007 6:22 PM (GMT -7)   
Greg,
 
I have the Federal Blue Cross/Blue Shield plan and they would not cover me either.  I was told I could write an appeal to the "board", but I feel that would probably be a waste of my time.  I ended up paying $113 for ten 100mg and I cut them in half for a 50mg dose.  That's 20 doses at 3 times a week...  or $17.00 a week.   I guess I used to pay that much for Starbuck's coffee each week and which I am not drinking now (makes you pee more!), so I guess it washes out.  It was still run thru my health plan, so I wonder if it will be included in my $4,000 yearly maximum catastophic limit, after which everything is free.  I am only about a thousand away from that limit with all the health issues year including my operation. 
 
I figured I would try the regular offical US prescription once (for six+ weeks), see how it was working and then maybe try to find a cheaper alternative.  I am near wrapping up my first 4 pills (8 doses) that were free with a coupon from the doctor.   They do seem to make a difference...  I am getting about a 20-25% erection at the 50mg and I had surgery 4/24 and just started the Viagra routine (3 times a week) 2 weeks ago.
 

Post Edited By Moderator (Admin) : 5/24/2007 10:37:09 AM (GMT-6)


kziz
Regular Member


Date Joined Feb 2007
Total Posts : 242
   Posted 5/22/2007 2:32 PM (GMT -7)   
Hi Greg, my husband has blue cross blue shields Oklahoma. It does cover his viagra. At first they were just giving us 3 pills at a time, which was causing us to take more trips to the pharmacy. He called bc/bs and they told him that they didn't have a limit. Maybe that can help you. He now gets 15 at a time, but I don't think that they pay very much, it still costs us about 10.00 per pill. The pharmacy said about 12 per pill without insurance. Good luck to you. Courtney
Kurt & Courtney
47 year old
Great Health prior to dx
Dx on 1/29/07
PSA 4.1
Gleason 3+3=6, both lobes
Stage T2c, I believe
Tumor involves 20% of cores, both lobes
Live in OK
Da Vinci scheduled 3-14-07 in Austin
Post-Op  Gleason 6, Stage t2c nx mx  YAAAAA HOOOOOO! 


lifeguyd
Veteran Member


Date Joined Jul 2006
Total Posts : 664
   Posted 5/22/2007 4:21 PM (GMT -7)   
I offered this same complaint awhile back. I found it insulting to be treated this way. I am on Medicare and they pay nothing. If your plan D does pay a portion it will be assessed at full cost against your "DONUT HOLE'. For those of you who don't know about this insidous Medicare Rx loophole, it was pushed through by Bushy and his cohorts to help bankrupt senior citizens. Hopefully the damage will be repaired in the future.

Actually you can buy some of these drugs online in generic form, but be sure to check out your source. I bought 100mg Viagra from Drugstore.com for about $10 each. This was direct and does not go against my "Donut Hole", sometimes called the GAP. Good Luck

Hey Kitt There was no illegal activity discussed, that I saw. Please don't over react, know your facts.
 
Biopsy 10/16/06
T2A,  PSA 4.7
Gleason 4+4=8 right side
adrenocarcinoma of prostate
DaVinci Surgery 01/16/07
Post op report,confirms Gleason4+4=8
no extra extension/invasion identified
age 65
Back on the golf course...
90 day PSA  less than 0.01 (undetectable)
 
 


Swimom
Veteran Member


Date Joined Apr 2006
Total Posts : 1732
   Posted 5/22/2007 8:30 PM (GMT -7)   
Hi Greg,

I just realized I made a goof...alldaychemist does not have tadalfil...they do have sildenafil and vardenafil.
I'm sorry I didn't see the error before now. Forgive my oversight.

Good Luck, Swim

pcdave
Regular Member


Date Joined Oct 2006
Total Posts : 444
   Posted 5/22/2007 10:57 PM (GMT -7)   

To Everyone:

Warning!  Buying ED prescription drugs in the US is very costly as we well know.  It is truly a sad situation when many insurers will not cover the cost of ED prescription drugs for PCa patients.  We face the same situation for many other miracle prescription drugs that are prohibitively expensive (especially if not covered by insurance), which may be needed for survival. This has forced many of us to seek the purchase of needed prescription drugs outside of the US at substantially lower cost, principally over the internet. The US government has been unable to readily police such purchases over the internet and is trying to rectify this situation for the future, hopefully to our benefit. In the meantime, there is a great concern about the quality of any generic drugs manufactured and sold outside of the US, and the possibility that they could be detrimental to your health, especially if they are counterfeit drugs.  Proceed with great caution! 

The following link indicates the FDA's current policy on importation of drugs.

 http://www.fda.gov/ora/import/traveler_alert.htm

You might be interested in reading this link relating to proposed "Regulation of Internet Pharmacies".

http://gregg.senate.gov/public/index.cfm?FuseAction=PressRoom.FloorStatements&ContentRecord_id=52fb8b9d-802a-23ad-4e3e-18cb9037e019&Region_id=&Issue_id=

Dave



68, 29-core biopsy 9/27/06, PSA 7.1, Stage T1c, Gleason 7 (3+4) [less than 20% in one area],  Gleason 6 [less than 5% in two other areas], negative DRE, bone scan and Endorectal MRI. Completed 39 Proton radiation treatments 2/22/07-4/18/07.
First PSA test to be taken 7/07.

Post Edited (pcdave) : 5/23/2007 12:31:28 AM (GMT-6)


Army45
Regular Member


Date Joined Dec 2006
Total Posts : 46
   Posted 5/22/2007 11:36 PM (GMT -7)   
GregM said...
I had robotic surgery on May 4. As part of the penile rehabiliation, I received a prescription for Viagra, 50mg every day. My insurance (Blue Cross Blue Shield of NJ) has denied my request for medical necessity. Nomal plan only allows four pills per month. Use of Viagra or other ED drugs "in erectile rehabilitions after prostatectomy is considered investigaional."


I suspect this is just the company line. Has anybody been successful appealing a denial for such medicine? Also, does anybody have a plan that provides coverage?



Good news, cancer was contained in prostate. I'm 53.


Hi Greg M, I have also tried to get my insurance plan (Green Shield up here in Canada) to cover the Viagra (or Cialis) but they won't touch it at all. At least your plan gives you 4 pills a month! I guess they figure you only need to get lucky once a week!

Army45
Diagnosed with Prostate Cancer in April 2006. Age 61 and no other medical problems - only take Thyroxin for thyroid but that has been for 40 years.
Surgery on July 7th, 2006 to remove prostate
PSA 7.5, Gleason 7 but downgraded to 6 after surgery biopsy.
T1-2
Lymph glands clean and cancer all gone - all within prostate.
Very minor leaking that ended after 3-4 months (1 pad per day)
2 month checkup - PSA "undetectable" 8 month check up PSA still "undetectable"
No further tests or treatment except PSA every 6 months.
Viaga now working and no longer use the Vacurect pump (for sale if any one interested!)


M. Kat
Veteran Member


Date Joined Jul 2006
Total Posts : 715
   Posted 5/23/2007 4:53 AM (GMT -7)   
BC/BS Federal plan does not cover the prescription either. we opted to use alldaychemist.com. I think in the future they will, but not now.
Husband Jeff 56 years old diagnosed July 27, 2006
PSA 6.5, 2 positive areas in biopsy, Gleason 3+3=6
Radical Retropubic Prostatectomy August 30, 2006
pathology report - all clear - cancer gone
1st post-surgery PSA test <0.1, 2nd post-surgery PSA test <0.1, 3rd PSA <0.1
no more pads Oct 12, 2006
first "real" erection with use of pump 12/16/06
3/07 - occasional dribbles and erections with Cialis and pump


GregM
New Member


Date Joined May 2007
Total Posts : 3
   Posted 5/23/2007 5:11 AM (GMT -7)   
Thanks to all who responded. It is interesting that there are some insurance companies that do cover this medication for PCa patients. BC/BS of NJ sent me a five page written policy explanation (Policy No. 040). In a nutshell, the policy states that there is not sufficient information to support the finding that such drug therapy is successful. Yet, some insurance companies believe the reseachs shows such therapy is successful and cover the costs. It's all a business decision.

Swimom
Veteran Member


Date Joined Apr 2006
Total Posts : 1732
   Posted 5/23/2007 11:11 AM (GMT -7)   
Sounds familiar Greg,

Paul's surgeon went to bat at a hearing that involved several of his patients. He gets a cookie and an A+ for his effort however, the insurance company stood my its opinion that there are no long term studeis on any post operative treatment involving PDE5 drugs currently available. They would not approve eating the cost of pills that cost 12-15 dollars each. Bottom line..... Approval of PDE5 drugs for men with a PCa hx is a patent expiration away in other words :>) Viagra is due to expire and Levitra right behind it..or is it Cialis that came 3rd? Anyway, it will happen in the not too distant future. Has anyone notice the major cost cutting moves Pfizer has made in anticipation of Lipitor and Viarga patent expirations? They haven't exactly been shy about why they have cut thousands of jobs. Tisk tisk tisk......

GregM
New Member


Date Joined May 2007
Total Posts : 3
   Posted 5/23/2007 6:46 PM (GMT -7)   
Normally, pharmaceutical patents are for 20 years. Viagra should expire in 2011 in the US and 2013 in the UK. I hope by that time everything will be working on its own. I'm sure that by the time the patents expire, a "new and improved" version will be available much like Nexium which was "an improvement" on Prilosec.

Swimom
Veteran Member


Date Joined Apr 2006
Total Posts : 1732
   Posted 5/23/2007 8:14 PM (GMT -7)   
Ha...maybe it takes a long time to move!

There is a huge research complex here that is closing its doors and moving to various parts of the U.S / world.
Every month when I go there, the crowd gets smaller and smaller. Between the news and being on site once a month, this is the scoop I've heard. Will the last one out of Michigan please turn out the lights!!!!

Swim :>)
 


kw
Veteran Member


Date Joined Nov 2006
Total Posts : 883
   Posted 5/25/2007 3:37 PM (GMT -7)   

    I have BC/BS Federal in Oklahoma.  I was denied even after an appeal.  I just ordered my "V" on alldaychemist.  I'll just get back at the insurance co by making them pay for my battle with the leaking.  I'll keep going to the Dr. and therapist as long as it takes.  Will cost them more in the long run.  I figure I got off to a good start with a 6 day stay in the Hopspital....lolol

  Good luck getting your insurance to cover the drugs,

  kw


    43
    PSA 5.7 - Discovered during Annual Physical with Family Practice Dr.
    Gleason 7
    Biopsy - 3 of 12 positive (up to 75%) all on left side of prostate
    RRP on Oct. 17, 2006 - Nerves on right side saved.
    All Lab's clear.  No Cancer outside prostate
    Cathiter in for 3 weeks due to complications in healing. Removed Nov. 9, 2006
    First Post op PSA on Dec. 11, 2006  Undetectable 0.00
    Office visit on Jan. 19th due to continued excessive urine leakage.
    Feb.20th Cystoscope and 2nd Post Op PSA. Another 0.00.....:)
    Dr. said everything looks fine.  Continue to work Kegeal's. Leaking appears to have improved  after Cystoscope?!?!?!  Down to 3-4 pads per day!
    March 1st  Leaking has crept back up to 6 - 8 pads a day ??????? 
    March 8th Started Detrol LA to see if it helps with the leaking?
    March 29th Collagen injection into sphincter / bladder neck area to control excessive leaking.  Worked for a couple of days then back to leaking.
    April 17th (Six Months Post Op) 2nd Collagen Injection to control excessive leaking.  Leaking started back next day at work!
    May 14th Second Opinion about my leaking and Options at OU Medical Center.  After reviewing my records the Dr. feels I will probably need some surgical intervention to stop my leaking.  But did agree to try Bio-Feedback and work hard on the Kegeal's first!
    May 30th Follow up with my Dr. and 3rd Post Op PSA.
    June 1st Start Bio-Feedback to try to control my leaking.
   


B&B's World
Regular Member


Date Joined Mar 2007
Total Posts : 120
   Posted 5/26/2007 6:54 PM (GMT -7)   
pcdave said...

To Everyone:

Warning!  Buying ED prescription drugs in the US is very costly as we well know.  It is truly a sad situation when many insurers will not cover the cost of ED prescription drugs for PCa patients.  We face the same situation for many other miracle prescription drugs that are prohibitively expensive (especially if not covered by insurance), which may be needed for survival. This has forced many of us to seek the purchase of needed prescription drugs outside of the US at substantially lower cost, principally over the internet. The US government has been unable to readily police such purchases over the internet and is trying to rectify this situation for the future, hopefully to our benefit. In the meantime, there is a great concern about the quality of any generic drugs manufactured and sold outside of the US, and the possibility that they could be detrimental to your health, especially if they are counterfeit drugs.  Proceed with great caution! 

We got some "viagra" from India, but B has found that it is different than the Pfizer issue, not consistently potent and sometimes there is no effect at all.



Age 51

Gleason 3+3

PSA from 3.2 to 4.3 in one yr

Biopsy 11/06

DRE negative

4 of 12 cores positive, one lobe, less than 10%

Inflammation only second lobe

Stage T1C Clinical Dx

PSA prior to surgery: 3.9

Da Vinci Prostatectomy 2/27/07:

PCa in BOTH lobes 5-10% of gland

Gleason 3+3

Negative tissue margins

Bladder, seminal ves, vas deferntia negative

Two inguinal hernia repairs

Catheter removed 1 wk after surgery

Full continence (no pad needed) 1 wk after surgery

Full potency, 12th day after surgery
 
 

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