The Oncologist, Vol. 10, No. 8, 561-562, September 2005; doi:10.1634/theoncologist.10-8-561
© 2005 AlphaMed Press
New Prescription Drug Benefit: The Role of the Oncologist
Jointly authored by officers of the American Society of Clinical Oncology and The CEO Roundtable On Cancer
Correspondence:
Joseph S. Bailes, M.D., American Society of Clinical Oncology, PO Box 131599, The Woodlands, TX 77393-1599, USA. Telephone: 214-725-6100; Fax: 936-273-9385; e-mail: bailesj{at}houston.rr.com; and David R. Brennan, President, CEO, AstraZeneca L.P., U.S., 1800 Concord Pike, Wilmington, DE 19850, USA. Telephone: 302-886-4701; Fax: 302-886-1889; e-mail: nancy.herczeg{at}AstraZeneca.com
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ABSTRACT
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Increasingly, cancer drugs are being developed for oral self-administration, and those oral drugs are frequently among the most sought-after by oncologists and patients, as their targeted mechanisms offer the promise of greater effectiveness with fewer toxicities. It is quite timely, therefore, that the Medicare program on January 1, 2006, will launch a new prescription drug benefit to cover, for the first time, oral and other self-administered prescription drugs for cancer and other diseases. The new benefit, Part D, is clearly a positive development for cancer patients, but it introduces new complexity to the process of selecting and financing prescription drug coverage. Oncologists, like other physicians, should be prepared to advise their patients concerning options for coverage.
Key Words. Medicare • Part D • Prescription drug reimbursement • Benificiary
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INTRODUCTION
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Most cancer chemotherapy historically has involved drugs delivered through injection by physicians or other providers. Increasingly, however, cancer drugs are being developed for oral self-administration, and those oral drugs are frequently among the most sought-after by oncologists and patients, as their targeted mechanisms offer the promise of greater effectiveness with fewer toxicities. It is quite timely, therefore, that the Medicare program is about to launch a new prescription drug benefit to cover, for the first time, oral and other self-administered prescription drugs for cancer and other diseases. Aside from welcome coverage of the important new targeted oral drugs, the Medicare program will also provide access to the many supportive-care drugs for treatment of nausea, vomiting, pain, and other side effects of chemotherapy. Oncologists have a critical role in making beneficiaries aware of sources of information, including the Centers for Medicare and Medicaid Services (CMS), that may assist them in making informed decisions about this significant new benefit.
On January 1, 2006, Medicare beneficiaries will be able to access self-administered prescription drugs through prescription drug plans implementing the new Medicare Part D. The new benefit, while clearly a positive development for cancer patients, introduces new complexity to the process of selecting and financing prescription drug coverage, so oncologists, like other physicians, should be prepared to advise their patients concerning options for coverage.
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IMPACT ON INDIVIDUAL BENIFICIARIES
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The Congressional Budget Office has estimated that Part D enrollees will spend (excluding premiums) an average of $792 less on prescription drugs in 2006, or 37% less than the $1,257 they would have spent without the benefit. Individual savings will vary substantially depending on the intensity and cost of the drugs utilized by different Part D enrollees. Plans available will differ, and patients should carefully consider their needs, plan costs, and formularies when deciding which options best meet their needs. For low-income beneficiaries with limited assets, Part D features significant support in the form of premium subsidies and greatly reduced copayments so that prescription drugs should be much more affordable for those patients.
In addition, Part D may especially help cancer patients with relatively high costs for oral cancer medications, as the copayment for the oral drugs (after $3,600 in out-of-pocket personal expenditures) will be only 5%. However, it is also projected that about one in four Medicare beneficiaries will spend more by enrolling in Part D than in the absence of the new benefit.
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CATASTROPHIC COVERAGE
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Plans will vary, including differences in deductibles, out-of-pocket costs, and the point at which catastrophic coverage and the 5% copayment begin. The law defines a standard benefit upon which actual plans will be judged as actuarially equivalent before approval. Under the standard benefit, the enrollee must cover as a deductible the first $250 of total drug costs. Medicare then pays 75% of costs between $250 and an initial coverage limit of $2,250. As total costs climb from $2,250 to $5,100, the enrollee is responsible for 100% of the costs in the so-called "doughnut hole." Only then, after total costs exceed $5,100 and total out-of-pocket payments for enrollees have reached $3,600, will the enrollee enjoy the 5% copay. Given the new challenges of this arrangement and the variety of choices, patients will need guidance from their physicians.
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PREVIOUSLY EXISTING COVERAGE
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Another potential source of patient concern has to do with rules pertaining to beneficiaries with existing coverage provided by an employer or union. If such coverage continues to be offered to beneficiaries by the employer or union and is at least as comprehensive, on average, as Part D coverage, then beneficiaries may want to continue it as long as it remains in effect.
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ENROLLMENT DEADLINE
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All potential Part D beneficiaries face a deadline for enrollment. The enrollment period starts November 15, 2005, and ends May 15, 2006. The next chance to sign up will be during the annual November 15–December 31 enrollment period. Those who fail to meet the May 15, 2006, deadline will be subject to an increase in premiums of at least 1% for each month of delay.
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INFORMATION SOURCES
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Two comprehensive resources are available:
The CMS has made available on its Web site materials that will assist organizations and practices in informing patients about Medicare’s new prescription drug benefit. These marketing materials are available at http://www.cms.hhs.gov/partnerships. As the beginning of the enrollment period approaches, materials that are targeted to individual beneficiaries will be available through CMS and the Social Security Administration, including tools to help patients identify plans that best meet their needs.
The Kaiser Family Foundation also has a wide range of informational materials on the drug benefit. In addition to documents that describe the history of the benefit, the foundation Web site includes a Medicare drug calculator to help beneficiaries determine how the Medicare prescription drug benefit will affect them. The Kaiser materials are available at http://www.kff.org/medicare/rxdrugbenefit.cfm.
As more information becomes available in the coming months, the American Society of Clinical Oncology (ASCO) will continue to update members through The Journal of Oncology Practice, ASCO News, the ASCO Web site (http://www.asco.org) and by regular Medicare updates.
CMS forms, patient materials and further information will be made available by The Oncologist at http://www.TheOncologist.com.
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IMPORTANCE OF PART D TO CANCER PATIENTS
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The new Part D benefit is critically important to cancer patients because it will give Medicare beneficiaries with cancer affordable access to new targeted oral therapies as well as the full array of supportive-care drugs for pain and other symptom management. It is the obligation of responsible cancer physicians to help their patients understand the potential advantages of this new Medicare benefit and how best to access it.
Oncologists treating patients—in partnership with patient advocates, industry, and others in the cancer community—should place a high priority on making sure elderly Americans with cancer take full advantage of one of the most significant new benefits since the beginning of Medicare.
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AUTHORS' NOTE
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Dr. Bailes and Mr. Brennan are acting on behalf of ASCO and the CEO Roundtable on Cancer, respectively.
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RELATED ARTICLES IN THE ONCOLOGIST
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McClellan, Mark. Help Your Patients Become Aware of the New Medicare Prescription Drug Plans.The Oncologist 2005;10:563–564.[Free Full Text]
Received August 19, 2005;
accepted for publication August 19, 2005.
This article has been cited by other articles:
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M. McClellan
Help Your Patients Become Aware of the New Medicare Prescription Drug Plans
Oncologist,
September 1, 2005;
10(8):
563 - 564.
[Full Text]
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Abstract
Introduction
