Bill Takes Aim at High Copays for Self-Injectable and Oral Cancer Drugs

Alan Lichtin, MD

With bipartisan support, legislation aimed at reducing the high copays for self-injectable and oral cancer drugs was introduced in the House and Senate.

The Cancer Drug Coverage Parity Act bill would require private health insurers to provide coverage for such drugs “on terms no less favorable” than those that are intravenously delivered or injected by a health provider, according to a Senate discussion draft of the legislation, which is supported by Representatives Leonard Lance (R, New Jersey) and Brian Higgins (D, New York).

“The Cancer Drug Coverage Parity Act won’t solve the problem of high drug prices, but it may help remove the large burden on some individual patients,” says Alan Lichtin, MD, chair of the American Society of Hematology (ASH) Committee on Government Affairs and a staff physician in the Department of Hematology and Medical Oncology at the Cleveland Clinic.

The legislation would prohibit private insurers from imposing requirements for prior authorization, step therapy, dollar or duration limits, copayments, deductibles or coinsurance that do not apply to provider-administered anticancer medications.

Insurers or group health plans would not be allowed to change benefits with the intention of increasing out-of-pocket costs, reclassify benefits in a way that would increase costs, or apply more restrictive limitations on self-administered cancer drugs unless those terms also apply to provider-administered drugs, according to the discussion draft.

Lichtin said that at least 37 states have parity laws of varying types but that a federal law is needed to provide greater uniformity, as certain health plans are not governed by state regulations. Lichtin has served as chair of the ASH committee for 3 years and says the legislative effort has continued throughout that time, involving one or more trips to Capitol Hill each year to meet with lawmakers. He believes the Parity Act stands a good chance of passage, as it has Republican and Democratic support.

“There’s a need for a full federal solution because different states handle it differently and different states have different insurance programs,” Lichtin says.

Nearly 40% of cancer patients fear going into bankruptcy over medical bills, according to a Cancer Support Community survey released in April. The Affordable Care Act has broadened access to health insurance for many Americans, though many are finding medical care remains out of reach because of the higher copays that are a feature of many of these plans.

High copays for oral medications that are typical of immunotherapy contribute to the problem, says Lichtin. “Some of these oral drugs are pretty expensive. We go through a preauthorization process to work with their insurance company so that we can understand what their out-of-pocket expense might be, and even for people with what they think is pretty good insurance, it could be over $1000 a month,” says Lichtin. “And that’s untenable for most middle-class people.”

There are programs available in many instances to offset the cost of drugs, but those don’t address the full need, Lichtin says. “There are people who can fall through the cracks, and we end up sitting down with them and the people say to me, ‘I can’t afford this, can we choose some other drug approach,’ and sometimes it’s hard to advise such a person. This is not an unusual conversation that we have.”

A statement from Higgins and Lance said that with oral chemotherapy becoming more common for patients with cancer, the high copay problem is growing worse, as these drugs are covered under the prescription drug benefit, which often places a higher percentage of cost sharing on the patient.

“Many patients are now using promising oral treatments but are forced to pay astronomical out-of-pocket costs or forgo treatment altogether,” Lance, a member of the Energy and Commerce Health Subcommittee, said in the statement.

“Today’s medicine allows some cancer patients the opportunity to take chemotherapy in the form of a pill at home rather than through an IV in the hospital; yet under the existing broken system, in some cases it is more costly to fill the prescription than spend hours in a medical facility under health care supervision,” said Higgins, a member of the House of Representatives Cancer Caucus.