A bill would bring down the price of co-pays on oral cancer drugs.

By Rose Hoban

When Amelia Borelli was first diagnosed with a form of leukemia in 2010, for treatment she went the traditional route of having intravenous chemotherapy.

But her first chemo treatment landed her in a coma. Borelli, 68, spent the next six months in the hospital and rehab.

“It knocked out that leukemia, but it nearly got me,” Borelli, a New Jersey transplant who now lives in Oxford, said.

Now, every day, Borelli takes an oral chemotherapy drug called Tasigna. But even with her insurance, the co-pay on the drug is about $1,500 per month.

“I don’t have it,” Borelli said. “I’ve been financially devastated since I got the leukemia.”

“Everyone,” she said, “knows what cancer costs.”

Borelli was at the General Assembly Tuesday to urge lawmakers to pass a bill that would require insurance companies to reduce co-pays on some of the expensive drugs required by cancer patients.

Borelli said that if she didn’t take the Tasigna, she’d be back in the hospital. Instead, she’s on a patient-assistance program run by the drugmaker Novartis, until October, that gives her the drug for a lot less. She said it doesn’t make sense that her insurance company won’t pay for the drug, but will pick up the tab for the hospital.

“I think I ended up paying maybe $200 out of the hospital stay,” Borelli said, “as opposed to the $1,500 a month [for the medication]. If I go back to the hospital now for therapy, my insurance will cover it.”

The bill before the legislature would make co-pays for oral drugs the same as co-pays for IV chemotherapy.

Different co-pays

Both supporters and opponents of the bill argue that one of the problems in the way insurance is organized now is that patients usually have separate deductibles for medical treatment and pharmacy costs. And when patients see a doctor to have IV chemotherapy administered, they pay the co-pay for the doctor visit, not for the drug they’re given.

But if that same patient goes to the drugstore to pick up a prescription, he might get hit with a huge co-pay for the drug. For many patients, those costs add up to a different deductible for pharmacy benefits. And for many patients, that big co-pay comes all at once. You either pay it right then, or you don’t get your medication.

Borelli said when she went to the pharmacy for the first time to get her Tasigna prescription filled, she balked at the $1,500 price tag.

“Never mind, I won’t fill it,” she recalled thinking.

Lisa Nelson, lobbyist for the Leukemia & Lymphoma Society, said that research has shown that when cancer patients are faced with a huge pharmacy co-pay, about a quarter of them will walk away, even from life-saving drugs.

“If you have a $2,000 prescription, its irrelevant what your total annual out-of-pocket is,” Nelson said. “That amount is so overwhelming to a cancer patient that they are not going to fill that prescription.”

But a spokeswoman for BlueCross BlueShield of North Carolina pointed out that once the Affordable Care Act goes into effect in January 2014, patients’ out-of-pocket expenses will be capped at a total of $6,350 per year for everything – medications, hospitalizations, doctor bills.

“And remember, new federal rules prohibit plans from turning away people because of pre-existing conditions, and in many instances people who need it the most will get financial assistance for their health insurance premiums, as well as assistance for paying for their medical care,” said Chris Evans, BCBSNC’s chief of regulatory affairs.

Evans told the House Health Committee Tuesday that passing the bill would effectively mean that her organization would be forced to give away the oral cancer drugs.

“In other states where this language has passed, Blue Plans have had to implement the benefit with zero-dollar cost sharing for the member because of the way the language is drafted in this bill,” Evans said. “In reality, though, these drugs aren’t free. Everyone will pay.”

Pricey medications

Evans also pointed out that with a bill such as this one, there’s little incentive or pressure on drug companies to lower costs.

“This bill will hide the costs of those drugs – moving away from the transparency,” Evans said. She pointed out that spending on oral cancer medications has increased dramatically in recent years, and that all of those medications are expensive.”

Borelli said that without insurance, her medication, Tasigna, would cost $4,085 per month.

Cancer patients are not the only ones who face potentially huge co-pays for medications. New generations of drugs for diseases ranging from multiple sclerosis to rheumatoid arthritis can cost hundreds per dose or thousands per month.

“We know that there are a lot of specialty drugs in the pipeline,” said BCBSNC spokesman Lew Borman. “We’ve been involved in specialty pharmacies taking a look at that and trying to implement change that way. This bill doesn’t move the issue in the direction that impacts cost or quality.”

Borman said BCBSNC predicts that such specialty drugs will account for at least 50 percent of the company’s spending on pharmaceuticals by the end of the decade.

Both Borman and Evans argued that another mandate on insurers could result in higher premiums for everyone.

That issue was something lawmakers in the health committee meeting were concerned about as well; they discussed referring the bill to the insurance committee for further review.

“Until we understand the financial implications of it, the ins and outs, we don’t need to step off a precipice,” said Rep. Marilyn Avila (R-Raleigh). “I want to know more.”

“I don’t have objections to more sets of eyes looking at a bill that affects the public policy of the state,” said Rep. David Lewis (R-Dunn), the bill’s primary sponsor. “But when it was filed and it wasn’t referred to [the insurance committee], it was because of written information received that the Department of Insurance doesn’t consider it a mandate.”

An amendment to refer the bill to the insurance committee failed by a vote of 10-8. The bill passed the committee on a voice vote and will be sent to the House floor.

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