How oncologic medications are covered in state health exchanges “might lead to new definitions and standards for medical necessity,” according to a study (“Analyzing the Affordable Care Act: Essential Health Benefits and Implications for Oncology”), by the American Society of Clinical Oncology. The authors review state-required oncologic drug classes in place now with respect to range — meaning, for instance, that Health Plan X might be allowed to cover no drugs in a certain class in a certain state while Health Plan Y decides to cover eight drugs in that same state. It also looks at the average for each class and how the drugs in the classes are most commonly covered in the states.
“Given the rapid technology innovation in the oncology drug category overall, the challenge for state exchanges will be to control care cost,” says F. Randy Vogenberg, RPh, PhD, principal of the Institute for Integrated Healthcare and a member of Managed Care’s Editorial Advisory Board.
F. Randy Vogenberg, RPh, PhD
Underwriting and actuarial equivalence requirements will most likely create unintended consequences state by state regarding coverage of any specific drug, especially newer generation brand drugs, he predicts. Medical device and diagnostic advances may provide better diagnosis under medical coverage sections of the exchange, but could face the same fate as drugs.
“Off-patent generic oncologic agents will become a bulwark for most state exchange formularies in order to create some level of consistency in coverage while containing cost and creating more predictability in coverage exposure,” says Vogenberg.
“Medicaid and insurance carriers participating in Medicaid will be challenged to provide essential health coverage while not bankrupting state budgets. How essential benefits get defined more clearly and operationalized will be an important step to determining whether state exchange coverage of cancer drugs fulfills the intended promise of health care reform expansion.”
| How anti-neoplastics are covered in states now |
|Class ||Examples of drugs ||Range ||Average ||Most common |
|Alkylating agents ||Altremine, chlorambucil, melphalan, lomustine, cyclophosphamide ||0–8 ||6 ||8 |
|Anti-angiogenic agents ||Lenalidomide, thalidomide ||0–2 ||2 ||2 |
|Anti-estrogens/modifiers ||Estramistine, tamoxifen ||0–3 ||3 ||3 |
|Anti-metabolites ||Mercaptopurine ||0–2 ||2 ||2 |
|Anti-neoplastics ||Not listed ||0–52 ||30 ||52 |
|Anti-neoplastics, other ||Fludarabine, leucovorin, mitroxantrone ||0–6 ||4 ||6 |
|Aromatase inhibitors, third generation ||Anastrozole, letrozole ||0–3 ||3 ||3 |
|Enzyme inhibitors ||Etoposide, topetecan ||0–3 ||2 ||3 |
|Molecular target inhibitors ||Erlotinib, gefitinib, everolimus, dastainib, imatinib, nilotinib, lapatinib, pazopanib, sorafenib, sunitinib ||0–11 ||10 ||11 |
|Monoclonal antibodies ||Rituximab ||0–3 ||2 ||3 |
|Retinoids ||Alitretinoin ||0–3 ||3 ||3 |
Notes: Columns 3–5 show the number of drugs covered. The report aggregates supplemental information regarding state EHB benchmark selection, provided from CCIIO regarding the EHB proposed rule.
Abbreviations: CCIIO, Center for Consumer Information and Insurance Oversight; EHB, essential health benefit.
Source: “Analyzing the Affordable Care Act: Essential Health Benefits and Implications for Oncology,” American Society of Clinical Oncology.