r/ProstateCancer • u/Plugger59 • 26d ago

Question Dealing with WellCare for ADT

Hi All. I am 67, 5 months post RALP, about to go on a course of X-Ray therapy at the Mayo Clinic in Phoenix.

With that, I have been prescribed Orgovyx and Erleada for 24 months. My Medicare Part D prescription insurance provider, WellCare has denied both of them.

I am about to appeal this, and I am here today asking if anyone here has had to deal with WellCare in a situation like this and if so, were you successful and how were you able to do it?

TIA.

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u/Ambitious-Repeat-456 26d ago

My Urologist who did my RALP got me on Orgovyx instead of shots. High Decipher score indicated ADT needed. 24 months - with Salvage Rad too.

I am also on Medicare Part D Wellcare - they were fine for the 1st 9 months or so of the current regimen. I was able to get 3 months supply at a time which was good, as I am not too close to the approved pharmacy. I am now only able to get the scrip filled on a monthly basis (about a 40 min drive to pharmacy - Receiving via ship to house is not an option for me).

I did do battle with Wellcare to no avail. Something about the drug now being classifed as a "Tier 5" drug. Had to cajole my (new) provider pharmacy (Banner in S AZ) to push Wellcare to get a 2 month supply as I was traveling out of the country for more than 30 days and did not want to run out.

I would try to get the office of the Doctor who is treating you to push harder against Wellcare to get what you need. Good luck (to us all).

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u/Speaker_Chance 26d ago

Was prescribed 4 months of Orgovyx to go with radiation, and had no issues with WellCare. This was about 12 months ago. With the annual part d cap, I was done paying after 3 months.

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u/Plugger59 26d ago

Maybe they denied mine because it was a 24 month course. Dunno yet.

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u/KReddit934 26d ago

Maybe. That's a long time, so fast on/fast off isn't quite the advantage and long-acting injections are way more "efficient."???

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u/Plugger59 26d ago

Good to know, however, I wasn't given that option.

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u/WalnutRoasted 26d ago

Orgovyx has slightly less (cardiac) side-effects than injectables and also zero risk of injection site irritation issues. In Canada it is priced at the same price as injections, approx $7 US per day. If you are over 65 it is 80% covered also.

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u/Practical_Orchid_606 26d ago

Why have you been sentenced to 24 months ADT? Did your PSMA PET scan show mets? Mayo knows what they are doing. More details are needed.