Better Coverage for Oral Chemo: Why It Matters

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When Gov. Deval Patrick signed an oral chemotherapy parity bill into law on January 5, Massachusetts joined more than 20 states requiring health plans to cover oral cancer pills at a rate no less favorable than standard intravenous (IV) chemotherapy. The new law tells insurers that they cannot require higher patient costs for oral chemotherapy, and it helps ensure that all forms of chemotherapy are accessible and affordable to Massachusetts cancer patients.

Insurers generally cover IV chemotherapy as a medical benefit – with a modest patient co-pay and a limit on annual out-of-pocket costs – while oral chemotherapy is treated as a prescription drug benefit, requiring some patients to pay a significant portion of the drug’s cost, with no annual out-of-pocket limit.

chemotherapy pillsThe new law ensures that oral chemo is covered at rates equivalent to IV chemo, and it has the potential to trim thousands of dollars in out-of-pocket costs for cancer patients receiving their chemo in pill form.

“The parity provided by this bill is a recognition that cancer treatment is changing,” says Dana-Farber President Edward J. Benz Jr., MD. “Increasingly, pills are replacing IV chemotherapy in the clinical setting, and some newer cancer drugs are only available in pill form. In fact, since 2012, eight of the 11 oncology drugs approved by the FDA are oral treatments with no IV equivalent.”

While chemotherapy pills and capsules have been around for years, they have become more common in the past decade, and experts see them as a critical part of cancer treatment in the future. For example, the drug imatinib (brand name Gleevec), which is the most effective treatment for chronic myelogenous leukemia, is only available in pill form, as is a newer medication, lenalidomide, used to treat multiple myeloma and myelodysplastic syndromes.

Oral medications account for around 25 percent of 400 cancer medicines currently in development, according to a 2008 report from the National Comprehensive Cancer Network. And researchers are continuing to uncover new potential benefits that may be gained through the use of targeted medications available only in pill form.

The new Massachusetts legislation earned broad support from a range of organizations, including the American Cancer Society, the Leukemia & Lymphoma Society, and Dana-Farber’s Legislative Action Network, whose members have actively lobbied legislators to enact this important bill since it was first introduced in 2009.

Learn how to manage oral chemotherapy at home through easy-to-use drug diaries.

Join the Legislative Action Network and help advocate for policies that improve the lives of cancer patients.

8 Comments:

  1. How do they determine a modest copay? What is modest for people making over 80k a year isn’t modest for us making under 50k. I do not live in MA but may be thinking about it soon because we cant afford to be sick in CT.

  2. I currently live in CT but will be moving to NH. Does anyone know if NH is one of the 20 states?

  3. Will Medicare now be required to cover oral meds such as Revlimid at the same rate as in-hospital meds?
    The out-of-pocket charges for oral chem on Medicare is significant.

  4. To answer a few questions that have been posed here:

    To date, 20 states and the District of Columbia have passed oral chemotherapy parity laws. Connecticut passed its law in 2010. New Hampshire has not yet passed such legislation, but it is studying the issue and previously passed a law to study the issue of parity between oral and IV chemotherapy. A PDF of the New Hampshire report is here:
    http://www.nh.gov/insurance/reports/documents/nhid_oralchemoanalysis2012.pdf

    The National Patient Advocate Foundation created a map last year showing states with passed or pending legislation.
    http://capsules.kaiserhealthnews.org/wp-content/uploads/2012/05/Oral-Chemo-Access-Map-May-2012.pdf

    The oral anti-cancer drug Revlimid should be covered under oral chemo parity laws. This article from the nonprofit Kaiser Health News takes a closer look at oral chemo parity legislation nationwide, and includes an example specifically on Revlimid.
    http://www.kaiserhealthnews.org/features/insuring-your-health/2012/cancer-drugs-by-pill-instead-of-iv-michelle-andrews-051512.aspx

  5. Error in above:Medicare Part A should cover ”in-patient” medications.Has Medicare commented on the parity rules?

  6. I just received notification from Blue Cross that my Gleevec (for GIST) is now available to me with no co-pay. And they’re reimbursing me for anything I’ve paid for it since the law went into effect. What a shock — a pleasant shock!

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