Lupron or Not at 76?

@jime51
Thanks. I'll check these options. My Part D plan covers Orgovyx with a pre-authorization. I need to check for how long - it might be limited to 12 months. Assuming I can get approved for the two years, the total cost would be about $7K because the max on out of pocket resets each January. If this is the best I can do it's not a financial issue.

@tbgb50 So you’re not under the Medicare $2100 Rx annual max. At 76, I wouldn’t take ADT for two years without significant metastasis indicated. Once you start, reevaluate at 3 months whether your quality of life on ADT is tolerable. If not, negotiate down.

Have you had a second opinion or two from prostate cancer centers of excellence like MD Anderson, Mayo, Sloan Kettering and others? This site is a great place to get information and gives you great information to be able to ask questions to the doctors. I wouldn't make your final decisions from information obtained here, even though it may be very good.
My doctors were happy I went to a couple of other doctors for their opinions. BTW, I'm 72 with a 4+4 Gleason a year and a half on ADT and I feel pretty damn good. I no longer need antiperspirant as I have no armpit hair and have lost most of my chest hair.
Before all his, I thought that I'd lose my eye for pretty girls, but thankfully it's still there, but I don't think I have the capability to do anything about anything. 😁

@heavyphil
Thanks for weighing in Phil. My dilemma is not so much that I would like to get off Orgovyx at 12 months instead of 18 (which I do), it's more about my Part D insurance. It only covers Orgovyx for 12 months. Open enrollment is October thru early December at which time I will have only been on the drug for 5-7 months. I doubt my oncologist would agree to a 12 month course at that point, so I will need to once again switch Part D providers during open enrollment to another provider that will cover Orgovyx. Otherwise I would max out my coverage in May of 2027 and be left with 7 months at $2000+ month out of pocket. The Medicare max out of pocket only applies to a drug that is in your plans formulary and only under the conditions of the coverage, which in my current plan is only 12 months. I'm doing pretty well on Orgovyx after a little over 2 months. If my oncologist insists I need to stay on it for 18 months, I trust him and will do so.

@carlsbadguy
I’m really puzzled by this. If the drug is in your formulary You’re being on it more months than they allow is not taking it out of the formulary. If your doctor requires you to be on 18 months, then those other six months should be covered by the Medicare limit.

Whoever your supplemental is for drugs, can’t tell you that the Medicare limit doesn’t apply because they think you can’t take more than 12 months. Many prostate cancer patients needed 18 months to two years. In my case, I’ve been on ADT for nine years, The Medicare limit counts because my doctor requires I be on it. It’s no longer that it’s not in their formulary. It’s not in their guidelines, which are almost definitely subject to a second opinion for those that have more advanced cases of prostate cancer.. You are not alone in this. There are a huge number of people that have to be on ADT for 18 to 24 months. You need to appeal this.

@jeffmarc
It is in my formulary as a tier 5 drug with a restriction/limitation of only 12 months coverage. I will certainly call them before I change providers, but not holding my breath they will extend coverage an additional 6 months. I understand many people are on this and other drugs for much longer than 12 months and their insurance pays for it. If you check your own formulary I'm sure you have no limitations of coverage.

@carlsbadguy
This says average duration 12 months. But that doesn’t seem to mean there’s a limit.

They would still have to supply it to you if your doctor prescribed it and if you hit the limit from Medicare, they could not charge you for it.

@jime51
I'm not planning on ADT for two years but if I did, the RX max resets every Jan. I'd pay $2100 for 2026, $2400 for 2027 (only full year) and I'm guessing $2500+ for 2028 since no one knows yet. I'm planning on one year unless something goes very wrong: 1. my PC is aggressive and 2. the urologist said I will not know for a year whether the ADT and radiation worked.

@jeffmarc
No, it says coverage duration is 12 months, which as I read it means they will only cover it for 12 months. Your reading glasses must have a smudge on them. 🙂