Oral Parity Update: It’s Time for Congress to Act

Posted in Advocacy, Cancer Care, Healthcare Reform by ACCCBuzz on May 7, 2012

by Sydney Abbott, JD, Policy Coordinator, ACCC

When technology outpaces policy, patients sometimes end up paying a high price. A good case in point is oral anti-cancer drugs, where out-of-pocket costs—even for well-insured patients—are often extremely high and burdensome compared to traditional intravenous (IV) infusions that require just an office co-pay (generally not more than $30). Prescribed oral anti-cancer medications, which fall under the pharmacy benefit portion of insurance drug plans, often require the patient to pay some percentage of the total cost of the drug, which can amount to thousands of dollars per month out of pocket.

We don’t often look to Medicare as a model for private insurance policy, but in the case of IV versus oral anti-cancer drugs, Medicare has already fixed the problem. Under Medicare Part D, any oral chemotherapy drug that is identical to an intravenous chemotherapy drug is covered under Medicare Part B’s medical benefits. Now, Congress is addressing the issue.

The Cancer Drug Coverage Parity Act (H.R. 2746) has been working its way through the House Health, Employment Labor and Pensions Subcommittee. Though moving slowly, the legislation is gaining new support. The bill now has 15 cosponsors, with recent additions Peter King (NY-3), Grace Napolitano (CA-38), Lois Capps (CA-23), and Silvestre Reyes (TX-16), among others. Those opposing the bill argue that it creates an insurance mandate for chemotherapy coverage. In fact, however, H.R. 2746 does not require plans to cover chemotherapy. Rather, it requires insurers already covering chemotherapy treatments to provide for coverage of oral anti-cancer drugs on terms no less favorable than the coverage provided for intravenously administered medications.

Congress is not the first legislative body to take up this issue. Since 2007, 18 states* and the District of Columbia have passed laws requiring health insurance plans to cover oral anti-cancer medications under terms no less favorable than those covered for IV chemotherapy infusions. Delaware, Maryland and Virginia are the two most recent states to pass oral parity laws. The laws in these three states actually require insurance plans to use consistent criteria when establishing co-payments for cancer medications, whether the treatments are administered orally or through intravenous injection (IV). This prohibits insurance companies from increasing doctor visit co-pays for chemotherapy to match pharmacy benefit co-pays for oral anti-cancer medications. Moving forward we can expect more states to adopt similar language. The Association of Community Cancer Centers (ACCC) worked in coalitions to help pass parity laws in Maryland and Virginia.

At the rate legislation is being passed in the states, it will take more than a decade to achieve oral parity for every cancer patient in the United States. Legislation at the national level would ensure equal access to the most appropriate treatment regimen for all patients, without raising the cost-sharing for patients to unreasonable levels. It is time for Congress to take action.

ACCC wants to see access to oral chemotherapy options protected for all cancer patients in the U.S. We will continue to fight to preserve our members’ ability to prescribe the most appropriate treatment for their patients. ACCC will monitor this issue and will notify members of state efforts in this area.

*Colorado, Connecticut, Delaware, Hawaii, Iowa, Illinois, Indiana, Iowa, Kansas, Maryland, Minnesota, New Mexico, New York, Oregon, Texas, Vermont, Virginia, Washington

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