POWER PERSPECTIVE

Oral Prescription Drug Insurance Parity (Part II)

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“Samantha

I am writing this as I just paid $3,000 in copays for 60 cancer-fighting pills. Why? Because I am a Medicare Part D patient and the medicine is over $11,000 per month. Federal insurance requires me to reach the “catastrophic level” before much more reasonable co-pays kick in, for me, next month. But no matter what, the effective oral medicine is paid much less fully by insurance than IV medicines. Why is that and what can we do about it? Read on!

I recently received an email from a fellow patient about oral drug parity (or lack thereof!)—the practice many insurance plans use to reimburse us at a higher rate if our medicine is delivered by IV, while they leave us with a higher copay if we take our cancer meds as a pill or capsule by mouth. The patient says, “I was totally unaware of this issue, as are many of us.”

While progress is being made on the state level, I too was disturbed to learn we still have not made progress with Medicare. So let’s take a closer look at this issue.

Back in April, 2009, the New York Times reported:

“Pills and capsules are the new wave in cancer treatment, expected to account for 25 percent of all cancer medicines in a few years, up from less than 10 percent now.

The oral drugs can free patients from frequent trips to a clinic to be hooked to an intravenous line for hours. Fewer visits might save the health system money as well as time. And the pills are a step toward making cancer a manageable chronic condition, like diabetes.

But for many patients, exchanging an I.V. bag for a pill is a lopsided trade, because the economics and practice of cancer medicine have not caught up with the convenience of oral drugs.”

Nine years later, the insurance industry still has not caught up. As The Times explained it:

“Start with the double ledger of drug insurance. Drugs that are infused at a clinic are typically paid for as a medical benefit, like surgery. Pills, though, are usually covered by prescription drug plans, which are typically much less generous.”

Why they do this is beyond our understanding. In 2012 in the Journal of the American Society of Clinical Oncology, Dr. Brian Durie of the IMF wrote that even though the purchase price of two myeloma medications was similar, “total cost per day was $48 higher for treatment with (injectable) vs. (oral) due to higher Medical management costs for (the injectable). The annual excess total cost of (the injectable) was $17,647.”

In other words, it costs more for a drug administered by a needle because of the doctor and office and clinic costs involved, as opposed to taking a pill with a glass of water at home.

So the IMF joined the campaign against this unreasonable disparity and supported patients testifying state by state. Here in California one patient was a single mother who had served as a Vietnam era Marine. Without insurance parity, she could not afford the copay for the oral drug her oncologist prescribed. She went to Sacramento twice to testify before House and Assembly committees, telling them, “The costs were so great I maxed out every single credit card… Not being able to pay for oral chemo forced me to take a drug that was not only less effective (for me), but left me so in debt I had to move in with my mother.”

The committees were riveted to her testimony. Even so, it took several tries for the bill to be signed by the governor.

Those early efforts led to the creation of PEAC, The Patients Equal Access Coalition. Today their map shows 43 states and the District of Columbia have enacted oral parity legislation. Even so that leaves patients in seven states unprotected. In March of last year one of our patients blogged about her efforts to get oral parity passed in Tennessee. It didn’t pass.

While most health insurance policies are regulated at a state level, which is why costs and benefits vary from one state to another, state law does not cover Medicare, a federal insurance program that actually is an amendment to the federal Social Securities act. Medicare serves approximately one in seven Americans and virtually all of the population aged 65 and over.

In the Congress, where legislation would change Medicare policy, a bill was first introduced by Congressman Brian Higgins, a Democrat from Buffalo, New York. All the way back in 2011 our friend the marathon runner Don Wright visited capitol hill to talk about oral drug parity legislation, but met with mixed responses. So the fight continues.

More recently, according to PEAC, H.R.1409 - Cancer Drug Parity Act of 2017 was sponsored in The House by Rep. Leonard Lance a Republican from New Jersey. The Senate does not even have a bill pending, and sponsors of previous legislation are no longer in the Senate.

So we need to get involved and contact our Senators and Representatives in Washington. Here is a link to locate your Senators and Representatives: https://www.govtrack.us/congress/members.  Tell them you are on Medicare and need the therapeutic your doctor prescribed, so you should not have a higher copay if your cancer medication is a pill instead of a needle in your arm. Ask your Representative to support H.R. 1409. Ask your Senator to introduce oral drug insurance parity legislation.

And remember, seven states still do not have oral drug parity. If you’re in Michigan, North Carolina or Tennessee support the fight for state legislation. If you’re in South Carolina or Alabama, Montana or Idaho the fight hasn’t even begun.

In 2009 the New York Times headline read, “AS PILLS TREAT CANCER, INSURANCE LAGS BEHIND.” Sadly, that still applies today. I hope this responds to the email comment that “many people are not aware of this issue”. And I hope it spurs us all to action.

As always, I welcome your comments. Please send them to me at comments@patientpower.info.

Andrew Schorr
Co-Founder, Patient Power LLC

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you. 

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Page last updated on February 1, 2018