Medicare insurance benefits leave coverage gaps for those requiring certain forms of chemotherapy treatment.
Of the 1.4 million new cancer cases per year, people over the age of 65 made up over 750,000 of these cases within the United States in 2008, according to Medscape Medical News. This population relies heavily on Medicare health insurance to cover the costs of chemotherapy, a commonly used cancer treatment approach. Gaps in Medicare coverage can affect benefit allotments for chemotherapy treatments.
Medicare Insurance Gaps
Traditional Medicare health insurance plans cover hospital and doctor visits under Parts A and B for individuals 65 years old or older. These are government-sponsored plans that carry standardized coverage rates, deductibles and co-pays. According to Medscape Medical News, coverage for medication costs fall under Medicare Part D, another plan type that must be purchased separately through a private insurance company. Cancer chemotherapy treatments vary in terms of drug type, how they're administered and the number of drug types used. Medicare benefits can fall short when individuals require oral chemotherapy treatments. This gap in coverage can result in high out-of-pocket costs. (see Reference 1)
Chemotherapy Treatments
Chemotherapy treatments can be administered in many different ways, some of which include oral, topical, intravenous, and intra-arterial. According to the American Cancer Society, these drugs target cancer formations and either stunt cellular growth or kill off existing cells. Developments in cancer research have made a number of oral treatments available for use, which enables patients the convenience of taking a pill as opposed to the more invasive treatment approaches. And while Medicare Part D does pick up a portion of these drug costs, the newer more effective medications are more expensive, which makes for higher out-of-pocket costs for patients, according to Medscape Medical News.
Medicare Part D
As of 2008, a standard Medicare Part D plan carries a $275 deductible, a 25 percent copay and an annual coverage limit of $2,510. Once the coverage limit has been met, a coverage gap of $3,216 must be paid before Medicare benefits restart, according to Medscape Medical News. Revlimid, one of the newer oral chemotherapy drugs, carries an annual cost of $74,000 when prescribed on a continuous basis. A more commonly prescribed drug, known as Gleevec, can run as high as $79,000 depending on the dosage frequency and amount. The high cost of these drugs can require patients to cover thousands of dollars in out-of-pocket costs due to gaps in Medicare Part D benefits.
Tier Classifications
Under the Medicare Part D plan, drugs can fall within different tier classifications that indicate how specialized or potent a particular may be. Drugs that fall within the higher classifications typically cost more, though Medicare benefit allotments may actually be less. In the case of the newer cancer chemotherapy drugs, many fall within the tier 4 classification, according to Medscape Medical News. As a result, copay amounts can run as high as 33 percent in addition to the standard deductible amounts and annual coverage limit restrictions.
Intravenous Drug Costs
When compared to oral chemotherapy drugs, out-of-pocket costs for intravenous treatments can run considerably lower under Medicare benefit coverage. According to Medscape Medical News, intravenous treatments administered in a doctor's office or hospital-type facility may be covered as a medical benefit under Medicare Part B. As of 2010, Part B requires a monthly premium of $110.50, a 20 percent copay and $155 annual deductible, according to Medicare.gov; however, a supplemental insurance plan can cover both the copay and deductible requirements.
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