Oncologists Frustrated Over Limits on Low-Cost Antiemetics

M. Alexander Otto, PA, MMS

May 26, 2022

Oncologists are calling on health insurance companies and pharmacy benefit managers to end quantity limits on low-cost generic antiemetics for patients with cancer.

While cost-containment strategies for newer and expensive options are understandable, the limits on these inexpensive products are not, say Waqas Haque, MD, an internal medicine resident at NYU Langone Health in New York City, and colleagues, in a strongly worded editorial published in the May issue of JCO Oncology Practice.

For example, limiting generic ondansetron to only nine tablets per month and/or requiring approval beforehand leads to needless suffering, delays in care, unnecessary burdens on clinicians, and extra costs when people end up in the emergency room for uncontrolled nausea and vomiting, they comment.

Strict quantity limits on antiemetics for home management of chemotherapy-induced nausea and vomiting are "inappropriate" and make no sense since most are available as generics for less than $10 a month, they add.

"It's a shame to the current system. Each of us should remember the last time we felt nauseated!" Haque and colleagues comment.

"There's no better example of a broken system than this," senior author Arjun Gupta, MBBS, a gastrointestinal oncologist at the University of Minnesota, Minneapolis, said in an interview.

"It's a lose, lose, lose scenario," he said. "Patients are hurt and clinically harmed; payers pay for the [downstream effects] and physicians and clinicians bang their heads against the wall" in frustration.

"It's such a joy and honor to be an oncologist, but things like this make my blood pressure rise," Gupta told Medscape Medical News. "I get it, people want to make money. Please make money, no one is stopping you, but just don't do it with such ridiculous things."

Gupta and colleagues are currently gathering the data they need to build the case for ending restrictions on low-cost antiemetics. "We need a lot of granular information about drug plan policies," but it's "hard to get because nobody wants us to expose what people are doing," he said.

As for the reasons for the current situation, there might be a lack of oncology-specific expertise at play, the editorialists suggest. Perhaps in a move to limit spending on newer antiemetics, payers have inadvertently put limits on products that aren't expensive anymore, or maybe they mistake the 3-day, 9-pill ondansetron prophylactic regimen as meaning that patients only need 9 tablets a month, which isn't enough to cover breakthrough nausea and vomiting. 

There might also be "perverse incentives" to, among other things, steer patients to newer treatments, the authors said.

Medscape Medical News sought to hear what payers had to say about the issue, so we reached out to the Pharmaceutical Care Management Association, which representants pharmacy benefit managers (PBMs). 

The group did not address the contents of the editorial but said through a spokesman that PBMs "have a proven track record of reducing prescription drug cost for clients and patients. PBMs exist to increase access to affordable prescription drugs, and help patients stay on their prescription drugs to live healthier lives."

Meanwhile, to counter quantity limits, oncologists are sending patients to discount drug websites like GoodRX and prescribing higher doses of antiemetics and asking patients to split pills. They're "imperfect solutions," Gupta and his team said.

Haque and Gupta have disclosed no relevant financial relationships. One co-author disclosed research funding from Varian Medical Systems, and another works for Flatiron Health, which is owned by Roche.

JCO Oncology Practice. Published in May 2022 issue. Full text

M. Alexander Otto is a physician assistant with a master's degree in medical science and a journalism degree from Newhouse. He is an award-winning medical journalist who worked for several major news outlets before joining Medscape and is also an MIT Knight Science Journalism fellow. Email: aotto@mdedge.com

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