Let the Buyer Beware

The disadvantage of oral chemotherapy treatment is financial – specifically in how it is currently handled by insurance companies. These therapies typically are classified as a pharmacy benefit for insurance purposes, rather than a medical benefit, as traditional IV treatments are. Because pharmacy benefits tend to have higher out-of-pocket costs to the insured, oral therapies may cost an insured person thousands of dollars more than the traditional IV procedure, even in cases where the actual costs of the oral therapy may be comparable to those of traditional treatments. A number of states have addressed this with legislation requiring insurance companies to treat oral therapy just like other cancer treatment. Missouri has not, but legislation has been filed in both the House and the Senate to force the same contract changes on Missouri insurers.

The forum this week was not so much to promote more government involvement in the marketplace, but to share information and experiences in other states with legislators and other affected parties. ALEC made it clear to me that it has taken no position on the appropriateness of legislative action but, at the request of Missouri legislators, it facilitated the informational meeting by inviting the experts who attended.

There is little debate about the personal and medical advantages of oral chemotherapy; the debate is over whether the state should demand that insurance companies cover these therapies as medical benefits rather than pharmacy benefits. Some would call that a state mandate, others a price parity issue. I am still studying the issue and have promised neither support nor opposition, but I do have some questions related to why insurance companies (the private sector) would not be both promoting this type of treatment and using coverage of it to differentiate and market their policies.

I believe there is something each of us can do to “help” the private sector do the right thing. Legislators who believe the problem demands a legislative fix contend that the reason for this price parity problem is uninformed customers. Most insurance clients know nothing about it until they need cancer treatment. They don’t know whether their health insurance requires higher out-of-pocket costs for oral chemotherapy than for traditional IV treatments – do you? I have inquired of my insurance company and found out that oral chemotherapy drugs are covered as a pharmacy benefit, not a medical benefit.

With the ObamaCare mandate, it is harder to make the distinction between insurance carriers. Nevertheless, it is worth the time to find out where they stand on oral chemotherapy coverage.

In the long run, your involvement could be much more effective than government intervention. Once you find out how your policy deals with oral chemotherapy, please contact my office; I would enjoy knowing what company provides your health insurance and whether it makes this valuable distinction between a typical pharmacy benefit and oral cancer treatment.