Caring Currents

Many More Cancer Drugs Covered by Insurance Thanks to New Medicare Rules

Last updated: Feb 04, 2009

IV drip
Image by that one asian used under the creative commons attribution no derivs license.

A quiet revolution in cancer care that started last November is beginning to make a big difference in treatment options for cancer patients.

What happened was this: Medicare, in response to a volley of complaints, finally loosened the guidelines permitting coverage of so-called "off-label" cancer drugs.

Those of us helping friends and family members fight cancer know only too well how frustrating the situation regarding insurance and off-label treatments has been. How many of us have listened eagerly as doctors suggested that our loved one's best option was Drug A or Drug B, only to find out it's not covered? 

Doctors themselves have been equally frustrated. Prescribing drugs off-label is extremely common in cancer therapy because oncologists will often keep trying one drug or combination of drugs after another until they find one that works. Years can pass during which doctors know that a drug tested on colorectal tumors also works against ovarian tumors, yet their hands are tied when it comes to prescribing it because insurance won't cover it.

In November, Medicare finally listened to doctors and pharmacists and decided to expand the number of drug guides that doctors can use to back up their choice of meds. Before this, oncologists were only allowed to use the American Hospital Formulary System, and critics argued that this fairly conservative guide was slow to recognize and recommend new treatments. Now doctors can rely on four different guides, and if any one of them indicates a drug is effective, that's enough to authorize its use. And while the new rules currently apply only to Medicare, other insurers are expected to follow Medicare's lead and expand what they pay for as well. Many, such as Blue Cross and Blue Shield, are already doing so.

Not everyone's happy, though; those focused on Medicare spending have been critical of the decision. A report by Peter Bach, MD, of Memorial Sloan-Kettering, in the New England Journal of Medicine warned of skyrocketing Medicare spending for the new drugs; Avastin, Erbitux, and Gleevac can cost $10,000 per month and up. The argument is that even though they buy cancer patients time, that time comes at a high cost given that the cancer is likely to prove fatal anyway.

Of course, if you or someone you love has cancer, you feel very differently; the news of expanded coverage has been met with cheers and sighs of relief from patients and caregivers. In many case, the new rules vastly expand the availability -- and affordability -- of  drugs that can make a life-or-death difference.  These include many of the newer cancer drugs, such as:

  • Avastin: Now available for ovarian, brain and kidney cancer in addition to other types previously covered.
  • Gemzar: Previously approved for four types of cancer, now approved for a dozen more.
  • Erbitux: Approved for several new types of cancer.
  • Rituximab: Was never FDA-approved for chronic lymphocytic leukemia, even though a combo known as FCR that includes rituximab is considered the "gold standard" of care for CLL. Now FCR should be covered.

With the economy in the shape it's in, this news couldn't have come at a more welcome time. The cancer patients I'm helping have struggled mightily to pay for cancer treatment, in some cases turning to charity or running up credit cards to pay for costs their insurance wouldn't cover.

Once again, those of us in Cancer World are raising our hands to say: "We'll take the extra time with our loved ones, thank you very much."