Medicaid May Require Approval For Some Cancer Drugs

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A state panel wants doctors to get prior authorization before prescribing certain chemotherapy drugs to Medicaid patients.

Advocates say that this will create dangerous delays in getting low-income cancer patients appropriate treatment.  The state insists that doctors will get prescribing authorization rapidly.

A governor-appointed Pharmacy and Therapeutics Committee advises the Department of Social Services on what medicines should be on the Medicaid preferred drug list. These drugs require no prior authorization and often are lower cost due to negotiated rebate agreements with the manufacturer. The committee voted earlier this month on the status of 13 oral oncology drugs, accepting the recommendations of a consultant, Provider Synergies, to put only seven of those drugs on the preferred list. One drug to make the list, Iressa, is not available in the United States.

“The recommendations they’re making fly in the face of clinical logic,” said Dawn Holcombe, executive director of the Connecticut Oncology Association. She said that doctors need flexibility in treating cancer patients and that adherence to a strict list would lower quality. Cancer is a very individual disease,” Holcombe said.

The wait time for authorization to use drugs on the list is central to the issue.

“It’s also important to note that ALL drugs are available to clients; it’s just that prior authorization is required for non-PDL (preferred drug list) drugs,” DSS spokesperson Kathleen Kabara wrote in an e-mail. “Prior Authorization must be completed in 2 hours and we closely monitor to make sure that happens.”

The administrator for a Connecticut oncology practice disputes this. Approvals take weeks in some cases, according to Anne Slam of Eastern Connecticut Hematology and Oncology. “The patient is waiting because their treatment is on hold,” she said.

Dr. Jeffrey Gordon, an oncologist who heads the department of medicine at Day Kimball Hospital in Putnam, said that Medicaid is usually quicker on granting prior authorization than private insurers.

“My experience in general has been that if I need a drug and I can say why I need it, I’ll be able to get it,” said Gordon, who chaired his own hospital’s pharmacy and therapeutics committee. Most of the drugs that are not on the preferred list have very specific uses, he said, which a physician should be able to document.

The prescribing changes will go into effect Jan. 1, if DSS Commissioner Roderick Bremby accepts the committee’s recommendations. DSS is preparing a response to several legislators and advocacy groups who have objected to the changes, DSS spokesperson David Dearborn said.

The U.S. Pain Foundation, Advocacy for Patients with Chronic Illness, Kidney Cancer Association, Witness Project of Connecticut, National Patient Advocate Foundation and Leukemia and Lymphoma Society all oppose the changes. “Federal law requires health plans to cover ‘all or substantially all’ oral oncology medicines. The federal government has found that this class requires special protections given the life threatening nature of cancer, and we believe that Connecticut should also take care to provide access to Medicaid patients for medically necessary medicines in an expeditious manner,” the groups said in a letter to Bremby.

Medicaid patients have higher mortality rates from cancer than privately insured patients, according to a 2007 American Cancer Society study.

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