Limits of reimbursement for anti-nausea tablets for cancer patients and doctors

Cancer patients can ward off sudden bouts of vomiting after treatment with relatively inexpensive anti-nausea tablets, but for some, the cost coverage reaches its limits.

Doctors say limiting the number of pills patients receive can interfere with treatment. Pharmacy benefit managers say their limits protect against overdose, and they offer workarounds to get more pills.

In between are patients who may take too few tablets or opt for less effective medication to combat a feared side effect of radiotherapy or chemotherapy.

The conflict shows how a variety of reporting and poor communication can make even simple Care actions in the fragmented USA Healthcare System.

“This is the dark side of the current health care system,” said oncologist Dr. Fumiko Chino. “Insurance companies and pharmacy benefit managers end up strangely in my exam room and standing between me and my patients.”

Steven Manetta takes at least half a dozen pills a day to keep a form of leukemia in remission. For more than a year, he rationed his standard anti-nausea pill, ondansetron, known by the brand name Zofran.

Manetta's health insurance through CVS Caremark covered 18 ondansetron tablets every 21 days, so to stretch his supply he was sometimes forced to resort to alternatives that made him extremely sleepy. He recently received approval for a 90-day supply.

“It's like one more thing you have to think about all the time,” said the 33-year-old resident of Lemont, Illinois. “When you're taking so many medications, you always go for the ones with the fewest side effects.”

Ondansetron came onto the market in the United States more than 30 years ago. It was the first in a series of drugs that helped doctors better manage nausea and vomiting, says Dr. Alexi Wright, an oncologist at the Dana-Farber Cancer Institute and a professor at Harvard University.

Wright and other cancer specialists consider ondansetron a cornerstone of treatment because of its relative safety, effectiveness and few side effects.

And the price is not to be sniffed at either: Thirty tablets of Ondansetron can be purchased on prescription discount websites for less than $12.

Pharmacists and doctors say they have struggled with restrictions on anti-nausea drugs like ondansetron for years. Wright says she finds the restrictions “annoying,” in part because the drug is affordable.

More than half of the plans offered in the U.S. private insurance market limit the number of ondansetron tablets patients can take, according to preliminary results of a study by Chino and Michael Anne Kyle, a researcher at the University of Pennsylvania.

Pharmacist Yen Nguyen often faces such restrictions, including the CVS Caremark restrictions that Manetta faced.

“With four or five months of chemotherapy, you’re fighting for every penny,” says Nguyen, managing pharmacy manager at Oncology Consultants in the Houston area.

Jennette Murphy paid cash for ondansetron when her cancer treatment began earlier this year because she couldn't afford the amount her doctor was asking for. Then she received a letter telling her the drug wouldn't be covered.

“It totally freaked me out,” said the Tehachapi, Calif., resident. “I was like, 'Seriously? Have you ever been through chemotherapy before?'”

Pharmacy benefit managers say they set caps partly based on treatment and give doctors multiple opportunities to request more.

Prime Therapeutics is limiting prescriptions of ondansetron in doses of 4 and 8 milligrams to 21 tablets over 30 days. This helps ensure a “maximum dosage” for seven treatment days per month, Chief Clinical Officer David Lassen said in an email.

He said quantity limits would be approved by independent doctors and pharmacists and would help prevent waste and overuse that may not be safe.

CVS Caremark spokesman Mike DeAngelis said his company follows Food and Drug Administration guidelines in setting maximum quantities. He added that the company can decide on requests for more pills in less than 24 hours.

Doctors say they don't always know when patients need more.

Coverage limits vary, and some patients may not tell their doctor that they received less than the amount they wanted. Additionally, the intensity of nausea can be difficult to assess with newer treatments.

Chino says patients should start with 90 tablets of ondansetron, which is enough to take the drug three times a day for a month if needed. However, she often sees upper limits of 21 or 30 tablets.

“The fact that there are still restrictive treatment patterns for this very useful drug is crazy,” said Chino, who recently moved from Memorial Sloan Kettering in New York to MD Anderson in Houston.

Restrictions could harm patients who have to pay high copayments for each refill or have difficulty getting to the pharmacy, notes Dr. Ramy Sedhom, an oncologist and palliative care physician at Penn Medicine Princeton Health.

“I have many patients who only go to the pharmacy once a month when their niece or nephew is in town to pick up (prescriptions),” he said.

If patients run out of ondansetron for even a few days, uncontrolled vomiting can lead to them needing to go to the emergency room or having their treatment interrupted, doctors say.

Murphy, the cancer patient, was able to avoid all of that. She said coverage for ondansetron began after her doctor at City of Hope Cancer Center requested it.

She must undergo a series of chemotherapy treatments that will continue well into the fall. The treatments leave her bedridden for days and feeling nauseous, even when taking ondansetron.

“I would hate not to have it,” she said.

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The Associated Press Health and Science Department receives support from the Science and Educational Media Group of the Howard Hughes Medical Institute. All content is the responsibility of the AP.