Download Vermont`s Oral Anticancer Treatment Access Law: What Clinicians

Vermont’s Oral Anticancer
Treatment Access Law:
What Clinicians Need to Know
Outdated coverage policies in Vermont USED TO limit cancer patients’ access to lifesaving drugs!
Traditionally, IV chemotherapy treatments are covered under a health plan’s medical
benefit where the patient is required to pay an office visit copay, usually between $20 and
$30. Conversely, oral anticancer medications are covered under a health plan’s prescription
benefit and, many times, patients are responsible for extremely high and unmanageable
copays, creating an enormous barrier for patients to access orally administered drugs.
According to a recent study published in the Journal of Oncology Practice and American
Journal of Managed Care, 10% of cancer patients failed to fill their initial prescriptions for
oral anticancer medications due to high out-of-pocket costs.
Legislative Solution
In an effort to remove barriers to accessing life-saving treatments for cancer patients,
Vermont enacted legislation, effective April 1, 2010 that directs health insurers who
provide coverage for cancer chemotherapy treatment to extend coverage for orally
administered anticancer medication at a cost to equal to intravenously administered or
injected cancer medications. To view Vermont’s oral parity law, please see next page.
What Does This Mean for Patients?
If a patient is privately insured by an individual or group plan,), and their plan covers
chemotherapy, an FDA-approved, orally administered drug should have the same out-ofpocket costs for the patient as an intravenously administered drug. The law does not apply
to patients on Medicare or those with a “self-insured” plan as both are exempt from
state law by the federal Employee Retirement Income Security Act (ERISA).
What to do if an insurance plan does not comply & to find out if the law applies to
your health plan:
Visit the VT Department of Financial Regulation at
http://www.dfr.vermont.gov/insurance/insurance-consumer/file-insurance-complaint
and click on “consumers” for information or contact Consumer Services at 1-800-964-1784.
For information about our oral parity work in Washington, DC, please go to:
peac.myeloma.org.
speac.myeloma.org
Vermont’s Oral Anticancer
Treatment Access Law:
What Clinicians Need to Know
LEGISLATIVE COUNCIL OF THE GENERAL ASSEMBLY FOR THE STATE OF VERMONT
TITLE EIGHT. BANKING AND INSURANCE
PART 3. INSURANCE
CHAPTER 107. HEALTH INSURANCE
SUBCHAPTER 11. ORALLY ADMINISTERED ANTICANCER MEDICATION
8 V.S.A. § 4100h (2012)
§ 4100h. Orally administered anticancer medication; coverage required [Section 4100h
effective April 1, 2010.]
(a) A health insurer that provides coverage for cancer chemotherapy treatment shall
provide coverage for prescribed, orally administered anticancer medications used to kill or
slow the growth of cancerous cells that is no less favorable on a financial basis than
intravenously administered or injected anticancer medications covered under the insured's
plan.
(b) As used in this section, "health insurer" means any insurance company that provides
health insurance as defined in subdivision 3301(a)(2) of this title, nonprofit hospital and
medical service corporations, and health maintenance organizations. The term does not
apply to coverage for specified disease or other limited benefit coverage.
speac.myeloma.org