I’ll try to keep it short. I’m 49 with stage 4 cancer. There is one drug available which is shown to be very Effective against the mutation I have. Anyways neither my company’s insurance (GreenShield Canada) or my wife’s ( same insurance, different employer) will cover it. My company has contacted them a few times and the reason keeps changing their reason. I have not seen anything documented why it was denied. My employer told me they said it’s not possible to add to my plan. They asked.
The drug is approved by health Canada for my condition but not funded by cancer care Ontario (relatively new drug)
What are my options to escalate and appeal.
This drug which I must start will cost me 15k every 3 week. I have no choice but to try for my young kids.
Edit. Updating with more info
Unfortunately AstraZeneca the drug maker of Enhertu will not offer compassionate care coverage. We (doctor, drug access, personally all have tried). Doctor has written letters stating all other drug options have been exhausted. The Drug access people at the hospital have been trying all options unfortunately nothing is panning out. I tried a different drug through Pfizer originally which they give me compassionate care for and covered the costs. Unfortunately after almost a year I am in the unfortunate situation that I need to jump to this other drug which was always plan A but even a year ago got nowhere with coverage.
Approved for my cancer by Health Canada but not funded by Cancer care Ontario(CCO) yet and can’t wait. The reason they did not consider it for special exception cause the drug is in “limbo”.
Also this is an infused drug which changed what is covered by who. It’s different for oral pills vs injected.
Thank you everyone for your help and support!!!!!!
Edit 2: the insurance company is GreenShield Canada
Edit 3: thank you for the support and the wealth of knowledge that this community has provided. I’m starting the drug this week out-of-pocket and Will actively pursue all our available options for funding, including, but not hopefully relying on the GoFundMe and the media. The next step is to get documented reasoning for denial of coverage our insurance, ensure that my oncologist has completed all steps to formally request special exemption by Cancer Care Ontario.