Until recently, drug therapy for patients with cancer consisted primarily of intravenous-infused treatment, but as we continue to develop new drug therapies, oral medications are becoming a part of this development process.
Anti-cancer medications that can be administered orally are a relatively new addition, and provide many benefits. These oral chemotherapy drugs are easier to take at home, helping to avoid a physician office visit or hospital stay. However, some insurance companies have decided that because these chemotherapy drugs are in a pill form, they should be reimbursed like a regular prescription drug.
Traditionally, IV chemotherapy treatments are covered under a health plan’s medical benefit, and the patient is required to pay office visit co-pay, usually between $20 and $30. Conversely, oral anti-cancer medications are covered under a health plan’s prescription benefit, and many times, patients are responsible for extremely high and unmanageable co-pays. These additional, out-of-pocket financial costs may result in the patient failing to fill the prescription.
A 2001 study by the Journal of Oncology Practice (JOP) and American Journal of Managed Care (AJMC), reports that 10 percent of cancer patients failed to fill their initial prescriptions for oral anti-cancer drugs. The study shows that while anti-cancer medicines offer benefits to patients, access to them is difficult due to high rates of cost sharing.
In an effort to remove the barriers to life-saving treatments for cancer patients, 20 states have enacted legislation that requires health insurance plans to cover orally-administered chemotherapy treatments. These laws remove the discrepancy in insurance coverage for oral and traditional intravenous or injectable forms of chemotherapy.
What does this mean for patients?
If a patient is privately insured and their plan covers chemotherapy, an FDA-approved, orally-administered drug should have the same out-of-pocket costs as an intravenously administered drug. The International Myeloma Foundation has been hard at work ensuring patients have access to treatments that are recommended by their physicians through the oral chemotherapy parity legislation around the country.
Now, they need our help in providing this information to the community oncologists and legislators of those states that have not passed the legislation.
The advances in oral biologic agents are most promising. In the fight against cancer, targeted agents represent a great leap forward. Without this oral parity, not all patients needing treatment will have equal access. This is yet another opportunity for nurses to advocate for patients.
Have any of your cancer patients experienced difficulty receiving insurance coverage for oral anti-cancer medications?
- Blesser Streeter, S. (2011) Patient and Plan Characteristics Affecting Abandonment of Oral Oncolytic Prescriptions. American Society of Clinical Oncology and Managed Care.