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With New Cancer Treatments Come Bigger Insurance Hurdles

Advances in targeted, personalized cancer care are on the rise.  So are health plan barriers that block patients’ access to tailored treatment. 

Health Plan Tactics Undermine Patient-Centered Care 

Great strides are being made in the care of many cancers, due largely to innovative testing and treatments that provide targeted, personalized care for patients. Yet barriers posed by insurance companies and pharmacy benefit managers increasingly stand in patients’ way.  

These can include: 

Prior authorization. Utilization management practices such as prior authorization, for example, can delay patients’ ability to access innovative diagnostic testing. Take biomarker tests, which are one way of determining whether a particular treatment will work for a particular patient.  According to recent data, nearly half of clinicians can’t give those tests without prior approval from an insurer.  

Step therapy. Meanwhile step therapy can also delay treatment by requiring patients to take older drugs before health plans will cover the drug originally prescribed by a patient’s clinician. The health plan’s required substitutions may or may not work as intended. And they can subject patients to disabling side effects, all while their cancer may continue to grow. Cancer advocates, including the Community Oncology Alliance, have been especially critical of step therapy.  

Non-medical switching. Oncologists say their patients are also being required to switch medications for non-medical reasons, a health plan-driven barrier known as “non-medical switching.”  The result? Less effective treatment, patient confusion, and a need for even more clinic visits.  

Formulary exclusions.  In some cases, health plans simply opt not to cover certain cancer patients at all. Formulary exclusions are becoming increasingly common

It’s little wonder that two-thirds of clinicians say insurance coverage is a barrier to offering the best cancer care.  

Policy Solutions for Cancer Patients 

If insured patients are unlucky enough to be diagnosed with cancer, they should at least have timely, uninterrupted access to the full range of innovative treatments.  That’s why individual states, and now the U.S. Senate, are attempting to protect patients with legislation limiting when step therapy can be required.  

These efforts build upon past policy initiatives to put commonsense guardrails against health plan barriers. If insurers and benefits managers will not respect the physician-patient relationship, policymakers are right to curtail damaging utilization management practices.  

With cancer, every second counts. These patients simply cannot afford delays in getting targeted care that can improve and even save their lives.  

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