In the world of Catch-22 situations, few dilemmas are more egregious for cancer patients than having to pay five times as much for treatment simply because they swallow a pill. Yet, this is the case today because Medicare and commercial health plans do not cover – and pay for – all cancer medicines equally.
The reason has to do with an outdated insurance system where intravenous (IV) drugs given in a hospital or oncologist’s office are called a “medical benefit” while the preferred pill form is covered as a “pharmacy benefit.” Rather than just semantics, the difference can be devastating for patients. Unlike a copay of about $100 a month for an IV cancer drug, insurers can charge patients thousands for a medication that comes in pill form. This is not only an injustice but this lack of coverage equity increases patient suffering, impedes medicine adherence and forces physicians to make decisions based on outdated health plan benefit designs rather than what is best for the patient.
Why Oral Parity Matters
The way we treat cancer is changing as newer oncology drugs – available in pill form – directly attack tumor cells, often with fewer side effects than conventional IV chemotherapy. Oral therapies are also less invasive, can be taken at home, and require fewer trips to the doctor’s office or hospital (an added benefit for patients who live in rural areas).
Thus, today oral anticancer therapies make up more than 40 percent of recently approved cancer drugs and many more oral compounds are in the pipeline. It is also worth noting that roughly one-third of new chemotherapies only exist in pill form, meaning patients treated with the newest and best therapies have no other option.
However, insurance practices often block patients from taking oral cancer drugs by burdening them with high deductibles, copayments and other costs. According to a Community Oncology Alliance sponsored study, oral cancer therapies are typically placed in the most expensive price tier in insurance and Medicare Part D plans, which means patients’ out-of-pocket costs can reach 25-50 percent of the drug’s total cost with no annual out-of-pocket limit.
The consequence should not be acceptable to anyone concerned with saving lives. When patients’ out-of-pocket costs are too high, they are likely to delay or forego treatment. According to one study, one in four patients with copays over $500 stop filling their prescriptions and don’t follow up with another oncology medication within 90 days. Similarly, a new study in the journal Clinical Oncology finds nearly 50 percent of patients will abandon cancer therapy when their out of pocket costs exceed $2,000. When this happens, patients get sicker, need more physician care, and end up in the hospital, and all of us pay in avoidable expenditures to the health system.
Especially now, when oral anticancer drugs are the wave of the future, it is time to address the inequitable coverage between oral and IV therapies by requiring health plans to cover all chemotherapy the same so patients pay the same cost percentage for each type of treatment.
Patients Rising NOW supports legislation that requires health plans to cover oral anticancer medications and injectable therapies equitably so that patients pay the same cost percentage for each type of treatment.
At the state level, we support enacting legislation so patients covered by individual and small business plans can afford the most effective treatments. Rather than mandating coverage of oral cancer drugs, these oral parity laws simply state that if a health plan covers chemotherapy treatment, patients’ out-of-pocket costs must be the same, regardless of how the therapy has been administered. To date, 43 states and the District of Columbia have passed legislation, and many cancer organizations and patient advocacy groups, including Patients Rising NOW, are working to enact oral parity laws in the remaining states.
At the national level, we support passage of the Cancer Drug Parity Act (H.R. 1409) to expand parity to cancer patients covered by federally-mandated plans like Medicare and employer-sponsored health plans. Introduced by Rep. Leonard Lance (R-NJ) and Rep. Brian Higgins (D-NY) in 2017, today the bill has bipartisan support from 140 cosponsors equally divided between Republicans and Democrats. Based on studies in states with oral chemotherapy parity laws such as Vermont, Texas and Indiana, passing the Cancer Drug Coverage Parity Act will have no appreciable effect on insurance premiums. One study found the cost to expand coverage to include oral chemotherapy for most benefit plans is under $0.50 per member per month (a mere 0.17 percent).
 Stein J, Mann J. Specialty pharmacy services for patients receiving oral medications for solid tumors. American Journal of Health-System Pharmacy June 2016, 73 (11) 775-796
 Community Oncology Alliance. Fact Sheet: Patient Access to Oral Oncolytics. Accessible at: https://www.communityoncology.org/pdfs/fact-sheet-oral-oncolytics.pdf
 Streeter SB, Schwartzberg L, Husain N, Johnsrud M. Patient and plan characteristics affecting abandonment of oral oncolytic prescriptions. J Oncol Pract. 2011;7:46s-51s.
 Lee Schwartzberg, MD, Casting Oral Cancer Drug Therapy in a Different Light, Oncology Stat, April 28, 2009
 Camacho FT, Wu J, Wei W, et al, Cost of oral capecitabine compared to intravenous taxane-based chemotherapy in first line metastatic breast cancer. Journal of Medical Economics.2009 Volume 12 No 3.