The Time Has Come to Modernize Coverage for Cancer Treatment

Guest Post by: Benjamin Stratton for the Komen Columbus Public Policy Committee

Today some chemotherapy drugs no longer require a hospital visit, IV, or needles. In fact, more than a quarter of the 400 anti-cancer agents in the pipeline today are intended as oral drugs and many of these oral drugs do not have an intravenous equivalent. Targeted therapies with reduced side effects, improved quality of life and better outcomes have been developed and often come only in the form of these oral chemotherapy drugs.

Unfortunately, health insurance practices have not been updated to reflect this new reality. Many policies split coverage into two types of treatment; “medical benefits”, meaning doctor’s services and hospital visits and “prescription drug benefits.”

Under a medical benefit, most patients pay the office visit co-pay for each treatment and not for the intravenous drug, while chemotherapy in the form of a pill is often classified under a prescription drug benefit and usually requires much higher co-pays. As a result, some cancer patients face hundreds or thousands of dollars in out-of-pocket costs every month – simply because they receive their chemotherapy in a pill rather than an IV.

Often, cancer patients who cannot afford the higher co-pays for oral treatment must resort to an intravenous treatment that may have not been the most clinically appropriate for their diagnosis. We have made great medical advances in our battle with cancer. The time has come to bring our insurance coverage up to date with those advances.

The Cancer Treatment Modernization Bill, Senate Bill 194, would ensure equity for patient out-of-pocket costs for oral and IV chemotherapy drugs by restricting the changes that health plan issuers can make to cancer chemotherapy treatment coverage.

Under SB 194, health plan issuers would be not be allowed to reduce coverage for orally, intravenously, or injected cancer chemotherapy medications by providing less favorable coverage through changes to coverage limits, copays, co-insurance, deductibles, or other out-of-pocket expenses. They could not move any such medication to a higher price tier or impose stricter conditions on treatments that use such medications.

SB 194 also prohibits “brown bagging” of chemotherapy drugs, in which a chemotherapy patient must pick up her drugs at a pharmacy and transport them the oncologist’s office, potentially jeopardizing the quality and safety of both the drugs and the patient.

According to the International Myeloma Foundation, 18 states have passed oral parity legislation and 12 states, including Ohio have bills pending.

SB194 does not mandate health plans to cover chemotherapy. It simply says that if a plan covers cancer treatment, then it must cover oral and IV treatments at an equal reimbursement rate. In addition, studies conducted in those states that have parity laws concluded that any increase in health care premiums would be negligible.

Komen is supporting this bill along with a number of other organizations such as the American Cancer Society, National Cancer Institute and the Ohio State University James Comprehensive Cancer Center. Please join our voices and ask your State Senator to support SB 194. Here is a link that lists Ohio Senators by zip code. In addition, we’ve provided you a form letter to send to your Senator.

We also welcome you to share your story about any challenges you may have in paying outrageous out-of-pocket expenses in order to receive oral chemotherapy drugs from your insurance company. Please email your stories to Julie Dean, Director of Mission to juliedean@komencolumbus.org

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