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Oct 20, 2016 11:08PM
I got my baseline DEXA scan the day I went for my radiation sim session, and it showed I was very osteopenic in the R femoral neck and moderately so in my c-spine. My MO wanted to put me on oral alendronate but I have a history of GERD verging on erosive esophagitis, so that was a nonstarter. I asked her about Prolia, because I’d read it was superior to I.V. bisphosphonates (Zometa, Reclast) in both strengthening bones and preventing bone mets. She said that the data on that wasn’t published yet (though she did admit that the next ASCO convention would probably announce new study results), that Prolia wouldn’t be covered, and that Zometa was “good enough.”
I wish my Medicare Part B (BCBS) or D (Humana) carriers would pay for Prolia. I have very difficult veins and it doesn’t help that my R arm is now off-limits for venipuncture. I also knew I would suffer severe side effects (“faux-flu” for days). Prolia is an injection and Zometa is an I.V. infusion. Zometa is covered, no questions asked, by Part B and its supplements because as an infusion which must be given at a facility (i.e.,chemo suite, hospital, clinic, doctor’s office), it is considered not a “drug” but a “treatment.” BCBS refused to cover Prolia because as an injection, it is at least theoretically possible to be self-administered (though in practice it never, ever is), and is therefore not a “treatment” but a “drug;” and Part B doesn’t cover “drugs”—that’s what Part D is for. But Humana Enhanced refused to cover any of it because Zometa is cheaper and is used for the same purpose. Prolia is $5K per shot, twice a year for three years. We have the money, but my husband says we should save it for a “rainy day,” i.e., if I get mets and need Ibrance, which is not covered, costs $9K/month without a co-pay coupon—and you can’t use any such coupons if on Medicare.
(That’s also why even my generic letrozole isn’t covered—Humana insists on my first “failing” a 3-month trial of generic anastrozole, and then the patient agreeing to take whichever mfr.’s generic letrozole the preferred pharmacy dispenses. I insisted if they wouldn’t cover branded Novartis Femara, I would take only Roxane or Teva letrozole, which have the fewest inactive ingredients and mildest side effects. Humana’s response was, because I specified a mfr., to call Teva or Roxane a "non-preferred brand,” which not only isn’t covered but doesn’t even count towards the out-of-pocket needed to pull me out of the “donut hole” and into “catastrophic coverage”).
So my MO’s nurse, at my insistence, said my MO would try for a prior auth. from Humana for Prolia but that it’d probably be denied “because they’re all cracking down on prior auths.” Not surprisingly, it was denied. (Wonder how hard she even tried). So I had to get a Zometa infusion. Just as I expected, it took 5 tries to get an I.V. started, the infusion hurt like hell while being pumped, and I was sick as a dog for nearly a week. I told my primary, and he was livid. He said that the latest studies prove that bisphosphonates strengthen only vertebrae, not long bones, and that they can cause some of the very fractures that they are taken to prevent. He is willing to cite my difficult veins, inability to draw from my right arm at all, and severe side effects suffered as justification for a prior auth. appeal—and he says he won’t stop at one attempt.
Diagnosed at 64 on routine annual mammo, no lump. OncotypeDX 16. I cried because I had no shoes...but then again, I won’t get blisters....
9/9/2015, IDC, Right, 1cm, Stage IA, Grade 2, 0/4 nodes, ER+/PR+, HER2- (IHC)
9/23/2015 Lumpectomy: Right
11/2/2015 3DCRT: Breast
12/31/2015 Femara (letrozole)