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Drug Costs and Benefit Design


Genevieve Kumapley, PharmD, BCOP, reflects on the significant out-of-pocket (OOP) costs associated with oral oncolytics and suggests how a change in benefit design can help patients afford the treatments they need.

“[Under the prescription benefit,] patients are required to now cover anywhere from 25% to 30% of costs, notes Dr Kumapley. “That’s significant.”

High costs burden patients and affect their adherence to treatment, remarks Dr Kumapley. For instance, patients prescribed high-cost drugs are less likely to fill their prescriptions, and although patient assistance programs are available to assist patients with the costs of treatment, drug benefit design should be reevaluated.

Dr Kumapley explains that currently, while intravenous therapies are covered under the medical benefit, oral oncolytics are covered under the prescription benefit. There is a large disparity in patient OOP cost, with the patient responsible for a higher cost under the prescription benefit. In oncology, she adds, coverage of oral oncolytics under the medical benefit may be more beneficial in terms of reduced patient OOP cost.

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