Imagine going to your doctor and hearing the words, "You have cancer!" To your surprise, your doctor provides great news about your treatment plan and informs you of a chemotherapy treatment that now comes in the form of a pill. You are pleased that you do not have travel back and forth to a clinic or hospital and you take your prescription to the pharmacy to have it filled. Upon arrival you learn that the medication is not covered under your insurance plan. Puzzled because you have full coverage and have never had problems having prescriptions filled in the past, you return to your doctor to inform her you cannot have your prescription filled because the out of pocket cost is astronomical. You then inquire about your options. You may find out the chemotherapy can be administered intravenously and then your insurance will cover the cost of the treatment. Or, you may learn that as modern medicine continues to advance, your treatment only comes in the form of a pill and is not offered intravenously.
Intravenously administered chemotherapy has been the standard cancer treatment since 1962. However, with the advancement of medical technology, oral chemotherapy has become the standard of care for many types of cancer diagnosis including certain types of metastatic breast cancer and was developed to improve patients' quality of life, provide a more convenient and less invasive method of therapy, and offer an alternative for patients who have failed to respond to other treatments. Unfortunately, health plans were originally designed to cover the cost of intravenously administered chemotherapy since oral chemotherapy was not available. Most medical benefits of a health insurance plan require a flat co-pay for services and supplies provided in the physician’s office or hospital outpatient setting, including the cost associated with intravenous chemotherapy. This bundling of services with a flat co-pay (which is usually not too expensive) makes it more affordable for patients to receive intravenous chemotherapy.
Conversely, oral chemotherapy is not covered under the medical benefit, but instead, is covered under the pharmacy benefit of the health insurance policy. Pharmacy benefit co-pays can vary by health plan (tiered co-pays, flat co-pays, percent coinsurance that increases with the cost of the drug) and may subject the patient to substantial out of pocket costs at the pharmacy counter for filling the prescription for oral cancer drugs. The out of pocket expense at the pharmacy counter creates a significant barrier to access for many cancer patients who are prescribed oral chemotherapy treatment.
Senate Bill 961 will alleviate this problem by making oral treatment options affordable. Please support SB 961 by contacting your representative to vote in favor of SB 961!