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"Six Month" Lupron, date for next injection? When does insurance cover it?

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Posted 9/20/2013 1:31 AM (GMT 0)
So I'm on 2 years of ADT with Lupron, and likely Casodex the whole time too. My first Lupron was a 6 month shot.

The documentation for Lupron 6 month depot shows the next injection date at 24 weeks, arguably 6 months. The problem I'm seeing is that 24 weeks is not considered 6 calendar months. So, what will the insurance company do? I have BCBS.

My uro's office warned me that insurance won't pay unless it is fully 6 months, plus a day or two for safety. My first injection was May 1. Thus a full 6 calendar months would end Oct 31. They scheduled my next injection for Nov 6, the following Wednesday. That's well over 24 weeks, actually 27.

I'm a bit concerned about testosterone rising during those last 3 or 4 weeks. We've wrestled my PSA below 0.1, and I don't want to give it any reprieve.

Does anyone have insight on the insurance company's coverage for this? I can't find anything conclusive on line. Or, a suggestion for the next step? Better to call the insurance company directly, or maybe have my uro's office contact them for preapproval?

Thanks in advance for any insights...
Posted 9/20/2013 1:45 AM (GMT 0)
My uro is very careful on the dates. In fact they have an Eligard date calculator that tells them to the day when the next shot sould be administered. Medicare is very tough on this and the insurance companies follow suit. I have usually been scheduled on the Thursday after the magic date as I can see my doc the last thing on Thursday and spend as much time as either he or I decide is needed.

Thankfully, I hope, my shot in August was my last and will take me through the planned three years.

As for a gap of a week or two, the med does not wear off quickly after the designated period. A week or two should present no negative issue.
Posted 9/20/2013 1:58 AM (GMT 0)
I would definitely call the insurance company. Lupron is an expensive injection. We had problems with the insurance not wanting to pay for my husband's Lupron & it was quite the ordeal getting it straightened out but it's all good now. When we went to get a second opinion the Dr suggested getting a 3 month injection next time, given in the stomach and the cost would be around $300, Charlie's first injection was a 6 month injection, given in the hip and the cost was $2800. Not sure why there is such a difference in cost or if one way is better than another. Anybody know the answer? I will contact the insurance company before going to the 3 month injection.
Posted 9/20/2013 3:28 AM (GMT 0)
My insurance pays at exactly six calendar months, not one day before. The specialty pharmacy can ship early, but it can not be delivered until the first day I could get the shot, so I have to schedule for afternoon injections of Lupron or Prolia.
For regular medical tests, six months means the day after the six months have passed, so tests move out one day each cycle.

It is an issue for this year, as weekends and holidays will push some tests & shots to the new year, so I'll blow my $3600 deductible the first week in January, rather than pay nothing the last few days of December. It isn't a long term issue (I'll blow the deductible by March regardless), but few of us are flush with excess cash the first week of January. I'll have to delay the shots for a few weeks.

There is NOTHING in PCa that you should do without pre-approval. Get EVERYTHING, no matter how supposedly minor, approved up front. EVERYTHING. Let me repeat .....
Posted 9/21/2013 9:10 PM (GMT 0)
FYI, I get one month Lupron shots, which are always scheduled at least 4 weeks apart. I've always been told that I could never go one day less than that or insurance would not pay. But the 4 weeks means that my 1-month shots are obviously slightly less than a month apart. I'm having my next one this Tuesday, which is 29 days since the one before, but I'm generally right on the 28-day cycle.

I'm not sure if the math would be any better for you if you were to take one month shots, nor do I know if it's even desirable for you to drag your butt into the office (pun intended) every month for your shot.
Posted 9/21/2013 10:06 PM (GMT 0)
Although Lupron Depot injections are referred to by the number of months, they are technically not "monthly" shots. They come in 4 week, 12 weeks, 16 weeks, or 24 weeks formulations.
Posted 9/22/2013 5:24 AM (GMT 0)
SC,

Interesting on the formulation. Regardless, my insurance pays at 6 calendar months. Clearly the days/weeks vary based on the length of the month, but they count months, not days. I suspect it is just easier for them. I have no real leverage, so I learn to deal with the system provided.
Posted 9/22/2013 11:40 AM (GMT 0)
SC and 142 - that's interesting. You've addressed what is probably real from both the manufacturer and the insurance company.

Manufacturer says, "Every 24 weeks". Insurance says "We can't keep track of that. Make it 6 calendar months."

I'll call the insurance myself, though it may be challenging to find someone there who can answer such a specific question.

Otherwise, I'll just have to color inside the lines and follow the urologist office's plan. Hopefully the extra couple of weeks won't matter too much. I'm on Casodex at 50mg/day, so that should help even if T does go up a little.
Posted 9/22/2013 3:12 PM (GMT 0)
If that's the way it's calculated, isn't there possibly a tiny benefit to taking the monthly, I mean 4-week shots? That way there's only 2-3 days missing per month, rather than a larger missing period between 24 weeks and the six months that insurance would pay?

Of course, I'm not sure if there's any appreciable difference in that approach.
Posted 9/22/2013 4:07 PM (GMT 0)
I have been following the "weekly" timelines with Unitedhealthcare. I am not aware of any insurance objections as long as I do not get a shot early to that timeline. I don't think being late a few days here or there is clinically significant. Once you are at castrate level, it takes months to recover. So, I think waiting a few extra days is not materially significant.
SC
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