Dec 19, 2012
By Steven Stranne, ASCO Policy Counsel
With the introduction of a number of highly effective oral cancer drugs over recent years, oncology professionals have witnessed an increasing number of troubling circumstances in which individuals with health insurance are unable to afford the most appropriate cancer therapy. To help address this, ASCO members and staff have been successful in working to support efforts to promote oral parity legislation at state and federal levels.
Legislatures in 20 states and the District of Columbia have enacted laws to help ensure parity between oral and intravenous cancer drugs, including state laws enacted in 2012 in Delaware, Louisiana, Maryland, Nebraska, New Jersey, and Virginia. Bills have also been introduced in at least a dozen other states.
The phrase “oral parity” refers to legislative initiatives intended to protect patients with cancer from high cost-sharing requirements that are sometimes associated with oral cancer drugs under health insurance plans. In many instances, individuals with health insurance face much higher cost-sharing requirements for oral cancer drugs than for intravenous or injected drugs administered in an office, clinic, or hospital setting.
The differences in cost-sharing arise from the typical structure of benefits under most health plans. Most intravenous and injected cancer drugs administered by a health care professional are covered under the medical benefit of a health insurance product. In contrast, most oral cancer drugs are covered under the prescription drug benefit. The cost-sharing requirements for patients (which can take the form of deductibles, copayments, coinsurance, and dollar limits) are often lower under the medical benefit and higher under the prescription drug benefit. In many instances, the most expensive oral cancer drugs are placed on a top tier of the prescription drug formulary, resulting in the highest possible cost-sharing requirements.
The need to protect patients against these unaffordable cost-sharing burdens has become more acute over the past several years. The introduction of new oral cancer drugs has provided options that in many instances represent significant clinical advantages over traditional intravenous/injected forms of cancer treatment. In some instances, oral cancer drugs represent the only viable treatment.
Oral parity bills typically have three components. First, the bills establish safeguards to ensure that patients can access oral cancer drugs under the same general cost-sharing rules as other cancer drugs, including intravenous/injected cancer drugs. Second, the bills define patient cost-sharing to include such obligations as patient copayments, coinsurance, deductibles, and dollar limits. Third, the bills attempt to create safeguards to prevent insurers from circumventing the intent of the legislation by reclassifying intravenous drugs or by other means. Oral parity bills are intended to provide targeted relief to individuals. As a result, there are no provisions that involve reimbursement for oncologists, pharmacists, or other health care providers.
Oncologists and other cancer care specialists have a unique role to play in educating policymakers about the need to protect patient access to oral cancer drugs. Our members can explain the critical clinical importance of securing patient access to oral cancer drugs and provide real-world examples of how these policies affect the clinical outcomes and lives of patients, emphasizing that access to oral cancer drugs is not merely an issue of convenience for patients or health care providers.
State oral parity laws are designed to govern the health insurance products that are subject to oversight by state insurance regulators. However, state insurance laws generally do not apply to self-insured employers, which are subject to the federal Employment Retirement Income Security Act (ERISA). There are a significant number of patients with cancer who are covered by ERISA health plans, as roughly 80% of employer-based health care coverage is governed by ERISA. Currently, ASCO is working with Members of Congress on federal legislation that would apply oral parity safeguards to the health insurance provided by self-insured (ERISA) employer plans.
ASCO has developed model legislation and other materials to assist advocates working to support these initiatives. For more information, contact ASCO’s Cancer Policy & Clinical Affairs Department at 571-483-1670 or publicpolicy@asco.org.
With the introduction of a number of highly effective oral cancer drugs over recent years, oncology professionals have witnessed an increasing number of troubling circumstances in which individuals with health insurance are unable to afford the most appropriate cancer therapy. To help address this, ASCO members and staff have been successful in working to support efforts to promote oral parity legislation at state and federal levels.
Legislatures in 20 states and the District of Columbia have enacted laws to help ensure parity between oral and intravenous cancer drugs, including state laws enacted in 2012 in Delaware, Louisiana, Maryland, Nebraska, New Jersey, and Virginia. Bills have also been introduced in at least a dozen other states.
The phrase “oral parity” refers to legislative initiatives intended to protect patients with cancer from high cost-sharing requirements that are sometimes associated with oral cancer drugs under health insurance plans. In many instances, individuals with health insurance face much higher cost-sharing requirements for oral cancer drugs than for intravenous or injected drugs administered in an office, clinic, or hospital setting.
The differences in cost-sharing arise from the typical structure of benefits under most health plans. Most intravenous and injected cancer drugs administered by a health care professional are covered under the medical benefit of a health insurance product. In contrast, most oral cancer drugs are covered under the prescription drug benefit. The cost-sharing requirements for patients (which can take the form of deductibles, copayments, coinsurance, and dollar limits) are often lower under the medical benefit and higher under the prescription drug benefit. In many instances, the most expensive oral cancer drugs are placed on a top tier of the prescription drug formulary, resulting in the highest possible cost-sharing requirements.
The need to protect patients against these unaffordable cost-sharing burdens has become more acute over the past several years. The introduction of new oral cancer drugs has provided options that in many instances represent significant clinical advantages over traditional intravenous/injected forms of cancer treatment. In some instances, oral cancer drugs represent the only viable treatment.
Oral parity bills typically have three components. First, the bills establish safeguards to ensure that patients can access oral cancer drugs under the same general cost-sharing rules as other cancer drugs, including intravenous/injected cancer drugs. Second, the bills define patient cost-sharing to include such obligations as patient copayments, coinsurance, deductibles, and dollar limits. Third, the bills attempt to create safeguards to prevent insurers from circumventing the intent of the legislation by reclassifying intravenous drugs or by other means. Oral parity bills are intended to provide targeted relief to individuals. As a result, there are no provisions that involve reimbursement for oncologists, pharmacists, or other health care providers.
Educating policymakers
Oncologists and other cancer care specialists have a unique role to play in educating policymakers about the need to protect patient access to oral cancer drugs. Our members can explain the critical clinical importance of securing patient access to oral cancer drugs and provide real-world examples of how these policies affect the clinical outcomes and lives of patients, emphasizing that access to oral cancer drugs is not merely an issue of convenience for patients or health care providers.
State oral parity laws are designed to govern the health insurance products that are subject to oversight by state insurance regulators. However, state insurance laws generally do not apply to self-insured employers, which are subject to the federal Employment Retirement Income Security Act (ERISA). There are a significant number of patients with cancer who are covered by ERISA health plans, as roughly 80% of employer-based health care coverage is governed by ERISA. Currently, ASCO is working with Members of Congress on federal legislation that would apply oral parity safeguards to the health insurance provided by self-insured (ERISA) employer plans.
ASCO has developed model legislation and other materials to assist advocates working to support these initiatives. For more information, contact ASCO’s Cancer Policy & Clinical Affairs Department at 571-483-1670 or publicpolicy@asco.org.