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Insurers rejecting newer cancer pills

When Jere Carpentier learned last year that she had advanced colon cancer — her third malignancy in a dozen years — she worried about spending hours in a clinic tethered to an intravenous line, enduring punishing chemotherapy that would make her hair fall out.

Carpentier was elated when her oncologist said this time she could avoid needles and take a pill at home that would specifically target the cancer cells and spare her hair. "I let that be the thing that made this OK," she recalled.

But the former human resources manager, who lives in San Jose, Calif., soon discovered that her insurer would not pay for the pill called Xeloda, which cost $4,000 per month, because a cheaper IV drug was available. So instead, she underwent surgery to implant a port in her chest through which she received 46-hour-long chemotherapy infusions, mostly at home. One night the device sprang a leak and began emitting a shrill alarm, requiring a race to the emergency room. "It was the scariest thing that happened to me," Carpentier, 60, recalled, "and I'd been through two cancers."

Scary and also unnecessary, in Carpentier's view. "Surgery for the port and the ER visit alone cost more than it would have for them to cover the... pill," she said.

Like Carpentier, a growing number of patients are being denied access to newer oral chemotherapy drugs or are required to shoulder hefty out-of-pocket costs, sometimes thousands of dollars a month, for cancer pills with annual price tags of more than $75,000. The reason is rooted in a reimbursement system that covers IV chemotherapy as a medical benefit but considers less-invasive oral chemotherapy to be part of a patient's drug plan, which tends to be far less generous. The disparity is likely to affect increasing numbers of cancer patients, because 25 percent of 400 chemotherapy drugs in the development pipeline are oral.

A recent report by the consulting firm Avalere found that oral cancer drugs, which account for about 10 percent of chemotherapy treatments nationwide, are typically placed in the most expensive price tier in insurance and Medicare Part D drug plans, where out-of-pocket costs can reach 35 percent. People covered by Part D plans in 2010 must shell out $4,550 before they get through the coverage gap called the doughnut hole, after which they pay 5 percent.

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