Chemotherapy for the Breast Cancer Patient and the Insurance Companies

I was directed to a YouTube piece titled “Protecting Cancer Care: Improving Transparency and Patient Access” that was posted by the Alliance for Patient Access, “a national network of physicians dedicated to ensuring patient access to approved therapies and appropriate clinical care. AfPA accomplishes this mission by recruiting, training and mobilizing policy-minded physicians to be effective advocates for patient access”.

“The ability to take a medication orally rather than having it infused not only allows for a patient to continue a more normal life but also has an added psychological benefit that can’t be measured.”Barbara Jacoby

This is a piece that I believe everyone who is or has ever been involved with breast cancer should read. And while every single issue addressed in this article needs individual attention, I would like to direct attention to the issue of the disparity with regard to injected versus oral medications.

Most of us are very familiar with chemotherapy that is injected. The patient travels to a treatment center and remains there for hours while the medication is injected directly into the vein. These trips are repeated for as many sessions as the oncologist recommends at designated intervals. However, with new medications that have been developed, some of the drugs are delivered in pill form only.

While the pills are not preferred for some patients depending upon their particular cancers, for those who are able to take the pills, this is a really great choice. Obviously it is so much easier to take a pill and go about your daily life uninterrupted rather than having to travel to a center for an infusion lasting a long time. And no one I know would rather have a needle to deliver their medication rather than being able to swallow a pill.

But here is the problem. Chemotherapy delivered in its usual form of infusion is covered by the guidelines of your medical plan. However, chemo in pill form is usually covered under your pharmacy plan that requires an out-of-pocket payment that may makes the drug unaffordable. If the drug is classified by the pharmacy benefit plan as “specialty tier”, that means a co-pay often ranging from 25% to 33% of the cost of the medication. As an example, if the annual cost of your medication is $60,000, your co-pay could range from $15,000 to $20,000. Most people can’t begin to afford this excessive cost.

Although 33 states and the District of Columbia have passed laws requiring insurers to provide parity for coverage of oral cancer medications that means that there are still 17 or 1/3 of the states that have no such requirements. Therefore, it is important to investigate the laws in your own State in order to find out the coverage that you have. If you find that you live in one of the States that currently has not created equality for coverage, why not start a campaign to make the change.

Perhaps you might need to enlist the help of a local organization who is willing to follow your lead and help others in this way. Or you might want to go directly to your local State representatives and plead your case. Not only will you be helping other breast cancer survivors but also you will find a focus for your own energies to make a difference.

Most likely you will find that a lack of knowledge and information is the reason that such legislation has not been enacted in your State. There is absolutely no reason why a chemotherapy drug should not be covered because of the manner in which it is administered. The ability to take a medication orally rather than having it infused not only allows for a patient to continue a more normal life but also has an added psychological benefit that can’t be measured. After all, if anyone needs as much help as possible when finding herself in the middle of a health crisis, it’s a breast cancer patient who needs chemotherapy