How Some Insurance Companies Are Able to Deny Chemotherapy Coverage

Oral doses of chemotherapy to be taken at home may seem like an improved, cost-efficient and more user-friendly option for many cancer patients, but — not. This convenient form of cancer chemotherapy is extremely expensive — often costing tens of thousands of dollars — and many health insurance policies do not cover it.

While most chemotherapy is still delivered intravenously at the doctor’s office or a cancer treatment clinic, about 10% of cancer treatment is now given in pill form. Pills and capsules are now available to treat cancers of the breast, colon, lungs, blood and more. Experts at the National Comprehensive Cancer Network expect that number to rise to 25% by 2013. The survival outcomes appear similar with oral and intravenous oncology drugs, and oral medications usually cause fewer side effects. Most patients find the pills less inconvenient, because they can take them at home rather than spending hours going back and forth to a hospital or clinic to have infusions slowly drip into their veins.

Outrageously, insurers are using a bureaucratic excuse to opt out of covering this type of treatment — despite the fact that it really is an improvement all around. Under private insurance and Medicare, chemotherapy infusions are considered “procedures” because they are delivered in a medical setting, and therefore they are covered by the same provisions that cover a visit to your doctor. However, chemotherapy pills are considered prescription drugs — and being much more limited, prescription drug plans often do not cover anywhere near the full cost of chemotherapy pills, if indeed they cover them at all. This is a perfect example of the difficulties presented by the infamous Medicare “donut hole” we’ve been hearing about. Medicare Part D, which covers most oral cancer drugs, requires a 25% co-payment. Once your yearly drug costs reach approximately $3,000, you must pay $3,000 or more out of pocket before coverage resumes.

Pills: The Future of Cancer Care

If your only chemotherapy option is a pill and your insurance doesn’t cover it, talk to your hospital social worker about alternate ways to pay for pills. Some organizations, such as the Chronic Disease Fund ( and the Patient Advocate Foundation (, provide financial assistance. If you can demonstrate financial need, drug companies also may help cover the cost of drugs. Calling a patient advocate who specializes in representing the patient’s interest is another possibility — see for information.

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