• Benign Prostatic Hyperplasia
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Advanced Prostate Cancer: Insurance Coverage of GnRH Agonists/Antagonists


Centering discussion on insurance and reimbursement, key opinion leaders in prostate cancer management consider the current state of coverage for GnRH agonists/antagonists.


Paul R. Sieber, MD: Chris, I’ll flip over to you on a slightly different question. From the standpoint of your insurers, are you having a lot of trouble with insurer pushback in terms of getting various products or has it been pretty much straightforward … it goes through relatively simply, or do you have a West Coast problem like Richard that you [are] told what to do?

Christopher M. Pieczonka, MD: No, we have a problem. We have a problem with mesylate with our local payer. Our local Blue Cross payer, I should say, probably is about 40% of our market, and right now, they’re not entertaining mesylate, which is the new kid on the block, at all. So that just takes that completely out of the consideration clinically. My hope would be that we’ll have a more even playing field on something like that, but that’s currently a problem, and I think that we’re all beholden to that. The last thing I want to do as a clinician is to have to look at somebody’s darn insurance and figure which medicine they’re on. In my mind, we pick a medicine clinically that we think is going to work, businesswise it’s going to work, you hit the button, and then they get it. And so, to have to ... drill down and see, oh, this is a local Blue Cross patient, I can't give them X, Y, or Z … it’s a hassle. It’s not what I want to do as being a physician. So we definitely have a problem with that here.

Paul R. Sieber, MD: Aaron, how about the Midwest?

Aaron Berger, MD: It’s variable. I think we’ve had pretty good luck getting mesylate approved in general, although there are still multiple managed care plans we’re involved with and some of the commercial patients [where] it still is challenging, and then we have to use the acetate. Our authorization folks of late have basically been, for the most part, trying to do the mesylate up front. So if someone orders, regardless of what’s ordered, they’ll check on the mesylate first, and then if it’s not covered, then we’ll do the acetate. So it’s pretty rare. These are given very similarly. It’s very unusual for a patient to say, oh, I want this one, or I want this one. I don’t think there’s enough differences in the administration that patients really know the difference. Obviously, there’s a big difference between IM [intramuscular] injections and subQ [subcutaneous] injections, and there are those patients [who] were on leuprolide intramuscularly [who] just liked it better, had fewer side effects. And some of those patients, we still [use] that drug, but for the most part, between the two subQ products, we do have some pushback for some payers, but in general, it’s been pretty good overall, probably 60% or so that we try to get mesylate, we can get, which obviously is still an issue, but our authorization folks are getting pretty good about knowing who covers it and who doesn’t, and then they won’t even bother if it’s one of the plans that doesn’t cover it. So, it’s a bit of a learning curve. You just try everything and then have a list. This doesn’t work; let’s not waste our time.

Paul R. Sieber, MD: That’s probably the advantage of being in the sticks. I don’t have quite as much of a hassle as you guys do. My interesting hassle is I have some insurers who require a different injection initially, and then you can switch over to mesylate, which makes no sense to me at all why I would give them a different product to be able to switch them over, but that’s what we see. Probably one of the unique things we see, my cardiologists around here love anticoagulation, love anticoagulation. Once you have a stent, it seems like you’re on dual agents for life, and we’ve had some issues with IM injections and hematomas. I’ve gotten a little bit gun-shy about IM injections when we have so many people either taking an antiplatelet plus aspirin, or they’re taking one of the new oral anticoagulants, and we give them an IM injection, they come back with severe buttock pain, and they got a big hematoma. So that’s been a nicer thing for us to shoot for the subQ just because at least we can put pressure on it, and at least not get the big bleed, but those IM injections make me a little bit anxious, that’s for sure.

Transcript is AI-generated and edited for clarity and readability.

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