Medicare prescription plans cover 75% of agents used to treat cancer, according to an analysis published in the current issue of Health Affairs. The study, by Bowman and colleagues of Avalere Health, reviewed cancer drug coverage offered by nearly 3,000 Medicare Part D plans’ formularies in January and February. The Washington-based health care advisory group self-funded the study. It did not examine data for infused chemotherapy drugs, agents used primarily in supportive care, or oral cancer drugs covered by Medicare Part B. It also did not evaluate beneficiaries’ access to drugs during the so-called “doughnut hole” gap in coverage.
Coverage differs significantly, however, and people with cancer should review prior authorization and other policies when choosing a plan, researchers cautioned.
Under a 2003 Medicare statute, Part D plans must cover “all or substantially all” antineoplastic agents. The study reported that plans cover 75% of anticancer treatments—99% to 100% of generics and about 70% of brand name offerings. Other findings include the following:
- The 20 most commonly prescribed anticancer agents were covered almost universally.
- About 10% of agents require prior authorization.
- Less than 5% of plans limit the amount of drug that a patient can obtain at one time.
- No plans require step therapy, in which patients must try lower-priced drugs before receiving coverage for more expensive options.
- Copays of $5 to $40 are more common than coinsurance. When coinsurance is applied, the most common proportion is 25%. Erlotinib is an example of an agent with a median copay of $40.
http://content.healthaffairs.org/cgi/content/abstract/25/5/1240
http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=3&DR_ID=39925
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