by Amanda Conschafter, blog editor
With new legislation on oral parity in both the U.S. House of Representatives and the U.S. Senate, disparity in insurance coverage between infusion and oral chemotherapy may soon be a problem of the past. Thirty-nine states already have laws requiring oral parity, and three states are considering bills this session. The Cancer Drug Coverage Parity Act was introduced to ensure parity for cancer patients with health plans not regulated by state law.
Oral anticancer medication has significantly increased treatment options for patients, largely because it can be taken in the comfort of the patient’s home rather than in a clinic or hospital environment. But medical innovations such as oral chemotherapy outpaced the health care reimbursement structure, creating barriers for patient access.
[Related: Rx Process: Why are some cancer treatments more expensive than others?]
Intravenously administered therapies are covered under the medical benefit, where most patients usually pay only a flat copayment for the office visit. Oral therapies, on the other hand, are often covered under a patient’s pharmacy benefit. They therefore carry a higher out-of-pocket cost burden for patients, especially because oral therapies may be placed on the specialty tier of the prescription drug payment structure.
Co-insurance rates applied to specialty drugs can be between 30 and 40 percent of the drug’s cost, requiring cancer patients to pay hundreds or thousands of dollars a month for their chemotherapy. Patients who cannot afford their medication may fall into non-adherence.
Parity legislation requires insurance companies to provide equitable coverage for both forms of chemotherapy. As bill sponsor U.S. Rep. Leonard Lance (NJ-07) explained, “Many patients are now using promising oral treatments but are forced to pay astronomical out-of-pocket costs or forgo treatment altogether. We have to fix this disparity in coverage so cancer patients are making health care decisions based on the best information, not which treatment fits into outdated guidelines.” The House bill is co-sponsored by Rep. Brian Higgins (D-NY). In the Senate, the bill was introduced as S. 1566 by Sen. Mark Kirk (R-IL) and Sen. Al Franken (D-MN).
For more on oral parity and challenges to cancer care, watch the Alliance for Patient Access’ “Protecting Cancer Care: Improving Transparency and Patient Access.”