Cancer Patient Battles Insurance For Chemo Drug Coverage

MIAMI (CBS4) -- There's a new battle brewing over which chemotherapy drugs are covered by insurance companies.

Traditionally chemotherapy drugs are injected intravenously in a doctor's office or hospital. Now, there are new, effective chemo drugs which can be taken by mouth. However, health insurance companies treat intravenous drugs and oral drugs differently, often requiring the patient to pay a much higher co-pay for a drug in pill form.

When Susan Kristoff was diagnosed in 2006 with stage IV metastatic cancer, her doctor prescribed a very effective new oral chemotherapy called Tykerb.

But Susan's medical insurance company refused to pay for it because it came in pill form.

"I would have had to pay for it out of pocket. It's $4,500."

Dr. Reshma Mahtani, an oncologist, has seen many patients struggle with this discrepancy.

"The problem is that intravenous therapies are covered under medical benefit whereas oral chemotherapies are covered under a pharmacy benefit. In the pharmacy benefit, patients are required to pay a proportion of the cost of the drug and that can be considerable."

And oral chemo drugs that have an intravenous equivalent are covered too.

"This drug, Zoloda, would be paid for because there was an IV equivalent," Mahtani explained.

Susan told her insurance company she intended to fight the decision publicly.

"I had had stories on the front page of The Palm Beach Post. I had been on Good Morning America about other insurance issues. And suddenly they just started delivering my drug," Susan said.

Even though Susan now gets her oral chemo drugs, she is worried about what will happen to other cancer patients.

"They have to pay a tremendously high co-pay of up to 50% that can add up to thousands of dollars," said Susan.

"What would happen is that they'd make a choice for a different type of therapy that's less effective, less targeted and it would lead to early demise," Mahtani added.

Susan G. Komen for the Cure is introducing new legislation which, if passed, would require insurance companies to pay for oral chemotherapy drugs the same way they do for IV chemotherapy agents.

For more information about breast cancer education, diagnosis and treatment, just go to this website, Susan G. Komen for the Cure Miami/Ft. Lauderdale Chapter.