Perjeta … Still on My Mind

… The weekend is upon us and I find myself still wondering.

If you have been following the Perjeta story, you know that my medical provider is requiring me to self-insure when I already have complete insurance coverage.  They told us that Perjeta will cost us between $60,000 to $72,000 outside of my regular insurance coverage.  Too funny, these people claim they have never received payment for Perjeta in the history of their practice, yet somehow its ethical to tell me that $500 advance payments each cycle are somehow a “reimbursable deposit.”

I’m glad I spoke to William first before giving them the credit card info – he just knew something wasn’t right.  William told me right up front that he was concerned that the requested $500 payment per cycle would unknowingly acknowledge a contractual obligation to self-insure Perjeta.  How this happens is beyond me.  This drug is fully covered according to the insurance company.  What good is insurance when non-medical types at an approved medical provider can tell a doctor we don’t care.  To be clear, this is not an insurance company problem. Their Case Manager has been wonderful.

I leave you with this.

Imagine yourself hearing that you are insured to receive a drug that will give you a 75% chance at completely killing off 4 tumors before surgery and if successful eliminates the need for follow-up chemotherapy.  Then, have a someone without a medical degree step in at the last-minute and withhold that treatment unless you agree to sign paperwork that essentially risks bankrupting you, all the while your insurance company fully covers this regime and has for a year.  Such a scenario isn’t exactly the peace and tranquility one needs!  Do you see what I see?  A big clinic with decent profits fed by hundreds, if not thousands of patients. A business that won’t take a contractually required financial risk, all the while trying to pressure me into doing just that?  I’m the little old lady who paid for insurance to cover this and they’re the pro who can’t figure out how to enforce their provider agreement with their insurance company customer.

I have faith though that things will work out.  If we can’t find a champion through the second opinion process, we will seek to stretch our credit line.  Although saying so is sharing personal matters, we are getting ready to list our high country home and selling this will relieve financial pressure on us too.  It is something we planned to do anyway, just more motivated now.  I’m especially encouraged by the research William has done.  He says Perjeta as “a standard of care” can be added in at Cycle 3 and completed in Cycle 6.  It would be at the lower end of the 4 – 6 cycle protocols listed in the NCCN guidelines, but clinically effective.  William also mentioned that my current 2-drug regime which includes one Anti-HER2 drug (Herceptin) was part of another 3-drug standard of care for many years which had a 17% chance of getting a 100% elimination of my tumors.  This means my current 2-drug regime may be holding its own against my tumors while we search for a way to introduce Perjeta.

Monday morning is big.  Getting a Second Opinion scheduled is critical.


Leave a Reply

Please log in using one of these methods to post your comment: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s