Each year, hundreds of enacted health insurance mandates or mandated offerings come across my desk to be looked at and analyzed. I tend to look for a pattern of what is the “popular” mandate being passed in a particular legislative year. This year, I noticed an upward trend in amendments or enactments concerning coverage for orally-administered cancer drugs.
When I saw these coverage mandates coming across my desk, my interest was piqued on a personal level. In 2009, my mother-in-law was undergoing treatment for lung cancer. Normally, the treatment protocol for cancer is to change medications once the current treatment has run its course. During her bout with cancer, she was faced with a recommendation to be treated with an orally-administered chemotherapy drug, Tarceva. Tarceva, approved in November 2004, is an oral self-administered treatment for advanced non-small cell lung cancer that has failed to respond to other therapy. I remember looking into whether it would be covered under her health insurance plan as it is extremely costly. In her case, her health plan covered the cost of the drug. However, after doing some research, I found that that may not be the case for some cancer patients.
Unlike conventional intravenous chemotherapy, oral chemotherapy can be administered at home, by mouth, as a liquid, tablet, or capsule. Most health plans do not categorize oral chemotherapy treatment as a medical expense; instead, it is often covered under the prescription drug component of the plan. Many health plans severely limit drug benefits and impose caps or annual coverage limits. As a result, the out-of-pocket expense of oral chemo treatment is much higher than the out-of-pocket expense of intravenous chemotherapy.
Many states have taken action to mandate that certain insurers provide equal coverage for oral and intravenous chemotherapy treatment. As of 2010, ten states enacted laws addressing insurance coverage for orally-administered cancer treatment. Laws in Colorado, Connecticut, the District of Columbia, Hawaii, Kansas, Oregon, and Vermont require specified insurers to provide coverage for oral chemotherapy under the same terms and conditions as coverage for intravenous chemotherapy. Laws in Indiana, Iowa, and Minnesota prohibit coverage for oral chemotherapy treatment that is less favorable than the terms and conditions of coverage provided for intravenous chemotherapy.
So far, in 2011, there are four newly enacted laws in Illinois (215 ILCS 5/356z.19 from HB 1825 effective January 1, 2012), New Mexico (Uncodified SB 385 s 1 through s 5 (2011) effective June 17, 2011), Texas (Ins s 1369.204 from SB 438 effective September 1, 2011), and Washington (Uncodified HB 1517 s 3 through s 6 (2011) effective July 22, 2011).
It will be interesting to see if any other states take similar action, although I suspect that it won’t be until next year that we see it happen.
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