Is Oral Chemo a Better Option? Maybe Not
by Sydney Abbott, JD, Policy Coordinator, ACCC
Kate, a 51-year old mother of three had surgery to remove a brain tumor. Six weeks of daily doses of two oral chemotherapies cost $10,800. Her insurance company paid $2,000. Kate’s provider told her that if she had taken the identical drug intravenously, she wouldn’t have paid a dime.
“It wasn’t presented to me as an option to do it intravenously. They told me, this is what you do,” Kate said.
Kate’s story appears in an article by Robert McCartney in today’s Washington Post. Her experience with oral anti-cancer drugs and her complaint are shared by many other patients.
Currently, about 10 percent of chemotherapies are available orally. However, up to 35 percent of agents in oncology development are oral medications. As more oral therapies emerge, many health plans are creating inequity and access problems for patients by covering infused chemotherapies at significantly lower out-of-pocket patient expense than oral agents.
Injected or infused treatments are typically covered under a health plan’s medical benefit, so patients are responsible for the office visit co-pay but not required to pay for the drug itself. Oral medications, however, are generally covered under a plan’s pharmacy benefit. Some plans require very high monthly co-insurance for prescription drugs, often thousands of dollars out of pocket for the patient each month.
Medicare has already fixed this problem. Under Medicare Part D, any oral chemotherapy drug that is identical to an intravenous chemotherapy drug is covered under Medicare’s medical benefit, Part B. H.R. 2746 is currently making its way through Congress to correct this issue for private payers, as well. It would require group and individual health insurance plans to provide for coverage of oral anticancer drugs on terms no less favorable than the coverage provided for intravenously administered medications.
Since 2007, 14 states* and the District of Columbia have passed oral chemotherapy drug parity laws.
That’s not enough. The Association of Community Cancer Centers (ACCC) wants to see every state with laws on the books protecting access to oral chemotherapy options for cancer patients. We will continue to fight to preserve your ability to prescribe the most appropriate treatment for your patients. ACCC will continue to stay on top of this topic and will notify members of state efforts as they become available.
*Colorado, Connecticut, Hawaii, Iowa, Illinois, Indiana, Iowa, Kansas, Minnesota, New Mexico, Oregon, Texas, Vermont, Washington
[...] care are debated in state capitols across the country, ranging from coverage of mammography to oral parity to the use to off-label therapy to the regulation of pain medication. (By the way, getting involved [...]
It does not appear that Medicare has adequately addressed the problem because many of the newer drugs will not be available intravenously – only orally. So the medicare requirement that it is identical to a drug that is available intravenously will NOT address the problem with the newest drugs!
I agree completely with what J. Turentine said above. The new oral chemotherapy drugs do not have an IV equivalent. Medicare does not cover this, and the new chemo-parity acts may have this loophole also, leaving patients unable to pay for their treatment drugs.