AfPA Position Statement, Cancer Therapy Parity
Orally administered anticancer medication has significantly increased treatment options for patients. However, medical innovations like this have outpaced the health care reimbursement structure, creating barriers for patients to use these treatments.
One of the most significant barriers is greater patient out-of-pocket responsibilities for oral therapies covered under the pharmacy benefit than out-of-pocket costs for intravenously administered therapies covered under the medical benefit. Intravenous anticancer medications are typically covered under a plan’s medical benefit, where most patients are responsible only for a copayment for each office visit and are not required to pay a separate fee for the IV drug. In contrast, oral anticancer medications are typically covered under a plan’s pharmacy benefit.
According to the Kaiser Family Foundation, the average coinsurance rate for “specialty” oral oncology drugs on a fourth tier of a prescription plan’s formulary is 36 percent. For a $3,000 per month oral anticancer medication, this could mean over $1,000 in out-of-pocket spending per month by a patient.
Oregon was the first state to enact a law (2008) requiring cancer therapy parity. It required state-regulated health plans to equalize patient out-of-pocket responsibilities for oral and IV therapies and stating that orally administered anticancer medication be covered on a basis “no less favorable” than IV or injected medications. The law cleared the way for patients to receive the best type of chemotherapy treatment for themselves, regardless of the drug’s formation. Legislation similar to the Oregon law is pending in other states, as health plans have opposed the adoption of parity legislation.
Policymakers must examine the issue of cancer therapy parity with the interests of patients in mind. Health plan benefits too often fail to equalize patient cost-sharing, thereby making oral therapies far more expensive than infused drugs. As a result, patients often cannot access the preferred therapy that their physicians determined to be appropriate, effective and safe.