Oral Parity: Taking It to the Next Level – March 2012

Sydney Abbott, JD

March 2012, Vol 2, No 2 - Patient and Provider Access


Imagine that you are a patient who has been recently diagnosed with cancer. While you are still recovering from a difficult surgery to remove the tumor, your oncologist ad­vises you it is time to begin chemotherapy. You are relieved to learn that your doctor has written a prescription for an oral anticancer medication, so you will not have to make weekly trips to the oncologist’s office for intravenous (IV) chemotherapy infusions. You promptly go to the pharmacy to fill the order. But, when it is time to pay for your prescription, you may not feel so relieved—especially when you compare the out-of-pocket costs for the oral anticancer drug to your copay for receiving chemotherapy infusions in the outpatient setting.

The oral medication may cost you thousands of dollars more per month than your health insurance plan covers. This disparity between insurance coverage of oral versus infused medications is a dramatic example of technology outpacing policy, and, as an increasing number of oral agents become available, more and more patients across the country are experiencing this disparity in out-of-pocket costs.

Out-of-Pocket Costs: IV versus Oral Drugs
Until recently, IV and injected treatments were the primary methods used in the treatment of cancer. However, oral anticancer treatments have become more prevalent, and for certain types of cancer, oral therapies are now the standard of care. Currently, approximately 10% of chemotherapies are available orally. Furthermore, up to 35% of agents in oncology development are oral medications. For some patients with cancer, oral anticancer medications are the only treatment—no IV alternative exists.

In addition, studies have shown overall higher costs associated with IV infusions when considering the physician and nurse time required for administration, not to mention the exponential rise in healthcare costs if there are complications from the administration of an IV therapy, such as an infection at the infusion site.

Insurance coverage policies have not kept up with the pace of cancer treatment technology. With the increasing numbers of emerging oral therapies, many health plans are creating inequity and access problems for patients, by covering infused chemo­therapies at significantly lower out-of-pocket costs for patients than oral agents.

Currently, IV treatments are covered under the medical benefit portion of health insurance coverage. This means the patient’s out-of-pocket cost is limited to the required copay for an office visit, which is usually between $20 and $30. By contrast, oral chemotherapy medications are covered under a health plan’s pharmacy benefit, which means that patients may be responsible for higher levels of cost-sharing. Out-of-pocket cost for prescription benefits is often some percentage of the total cost of the anticancer medication. Therefore, these copayments can amount to thousands of dollars monthly, and in extreme cases, they can cause patients to forgo necessary treatment altogether.

State versus Federal Legislation
States have recognized the seriousness of this problem, and since 2007, 15 state legislatures—Colorado, Connecticut, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Minnesota, New Mexico, New York, Oregon, Texas, Vermont, and Washington—and the District of Columbia have passed laws requiring health insurance plans to cover oral chemotherapy regimens under terms no less favorable than those offered for IV treatments. As of the publication date of this article, Maryland, Virginia, Missouri, and others are also considering similar legislation. But at the current rate that legislation is being passed in the states, it will take more than a decade to reach oral parity for every patient with cancer in the United States. Legislation at the national level would ensure equal access to the most appropriate treatment regimen for all patients. It is time for Congress to take action.

Medicare has already fixed this problem. Under Medicare Part D, any oral chemotherapy drug that is identical to an IV chemotherapy drug is covered under Medicare Part B’s medical benefits. Only private payers are not yet required to update insurance policies to keep pace with the changing landscape of quality cancer care.

Last fall, Congressman Brian Higgins (NY-27) introduced the Cancer Drug Coverage Parity Act of 2011 (H.R. 2746). This bill, which is still making its way through Congress, has many supporters but has faced opposition from those who are concerned that this is a mandate. However, H.R. 2746 does not propose to require plans to cover chemotherapy. Rather, it requires insurers that already cover chemotherapy treatments to provide for coverage of oral anticancer drugs on terms no less favorable than the coverage provided for intravenously administered medications.

The Association of Community Cancer Centers (ACCC) wants to see access to oral chemotherapy options protected for all cancer patients in the United States. We will continue to fight to preserve our members’ ability to prescribe the most appropriate treatment for their patients. The ACCC will monitor this issue and will notify members
of state and federal efforts in this area.