Alexandria, Va., September 13, 2012 – The Academy of Managed Care Pharmacy (AMCP) sent a letter to California Governor Jerry Brown last month urging him to veto AB 1000, a bill that would require providers of pharmacy benefits in the state to cover oral chemotherapy agents at the same cost-sharing level as intravenous (IV) or injected chemotherapy agents.
The legislation would apply to all health care service plan contracts renewed on or after July 1, 2013, and which provide coverage of outpatient prescription drugs. The bill would prohibit health insurers from charging policyholders more for covering oral chemotherapy than for intravenous chemotherapy. It also would prohibit health plans from increasing cost-sharing for IV or injected agents in order to meet the requirements of the legislation.
“Of utmost concern to our members is making sure that our patients receive the right medication at the right time,” AMCP says in its Aug. 28 letter. “They work diligently to design and administer evidence-based, affordable prescription drug benefits. Like many patients, our members are extremely concerned about the impact that rapidly rising prescription drug costs, including costs for certain newer chemotherapy agents, have on patient access to these treatments, especially those which are clinically superior to other available treatments.”
The letter noted that when designing a prescription drug benefit, several factors must be taken into consideration.
Currently, if one treatment is shown to be more effective than other treatments, or to have a higher clinical value in comparison to other treatments, a plan may choose to offer more favorable cost-sharing requirements for that treatment relative to other treatments. This benefits patients by offering coverage of more effective treatments at the most affordable rate and also benefits payers by maximizing the value of dollars spent on treatment.
Another consideration is the risks and benefits associated with both oral and IV chemotherapy treatments. With the relatively recent increase in availability of oral chemotherapy agents, best practices regarding their administration are rapidly evolving. Additionally, health care professionals are collecting and analyzing “real world” data to evaluate patient adherence and outcomes associated with oral chemotherapy.
While oral chemotherapy agents are more convenient for patients, especially those who live far away from an infusion center or physician’s office, they also place the burden of correct administration of the drug entirely on the patient or their caregiver.
There are also questions regarding the appropriate management of any side effects that a patient receiving oral chemotherapy may experience and how that may affect patient adherence. On the other hand, IV chemotherapy treatments can be less convenient for patients, and can also introduce the increased risk of infection, but patients are under the supervision of a health care professional who can ensure proper administration and help to manage any side effects at the time of treatment.
“Cost-sharing parity mandates remove tools from health plans that enable them to retain the flexibility to adjust benefit design in response to the latest medical evidence for the benefit of patients,” AMCP said.
Finally, AMCP said, this legislation does not address the root cause of the problem: the high costs of these treatments.
“Because many of the treatments that would be subject to this requirement have no generic or therapeutic alternative, it is difficult for health plans to negotiate more favorable prices from manufacturers,” AMCP said. “Reduced cost-sharing does not lower the overall cost of the prescription drug. Instead, it simply shifts those costs back to the health plan. This could have the unintended consequence of actually increasing costs, not only for patients receiving treatment for cancer, but for all of the patients covered by the pharmacy benefit.”
To read the entire Aug. 28 letter, click here or visit AMCP’s Letters, Statements and Analysis webpage at www.amcp.org/2012.