January 10, 2014 — Insured women with a high risk of developing breast cancer will be able to receive certain preventive drugs at no out-of-pocket cost beginning in September, HHS announced on Thursday, Kaiser Health News' "Capsules" reports (Galewitz, "Capsules," Kaiser Health News, 1/9). The rule applies to all Medicaid and Medicare plans, as well as private plans (Kennedy, USA Today, 1/9).
Under the Affordable Care Act (PL 111-148), health plans must cover preventive services and treatments without a copayment or deductible if they are rated A or B by the U.S. Preventive Services Task Force, an independent panel of physicians and academics ("Capsules," Kaiser Health News, 1/9).
Background on Breast Cancer Recommendation
In September, USPSTF recommended that women with at least a 3% chance of developing breast cancer over the next five years should consider taking one of two FDA-approved breast cancer drugs, as long as they have a low risk for related side effects. The recommendation was based on a systematic research review published in the Annals of Internal Medicine.
Specifically, the panel said the chemotherapy drug tamoxifen or the osteoporosis drug raloxifene should be considered for women whose five-year risk for breast cancer is calculated to be at least 3% by one of two reliable risk calculators -- one from the National Cancer Institute and another from the Breast Cancer Surveillance Consortium. However, for women with certain risk factors, such as a family history of stroke or blood clots, the chance of adverse effects from the drugs could outweigh the potential benefits.
The panel's endorsement applies to women with no history of breast cancer, ductal carcinoma in situ or lobular carcinoma in situ. The recommendation does not apply to women who have the BRCA-1 or BRCA-2 gene mutations, nor to women who are younger than age 35 or older than age 79.
Overall, USPSTF issued a grade B endorsement for the drugs for eligible women and a grade D on preventive treatment for women who did not meet the guidelines (Women's Health Policy Report, 9/24/13).
In a blog post, HHS Secretary Kathleen Sebelius wrote, "We are making significant advancements in combating this disease -- and for women who are shown to be at a higher relative risk for breast cancer, today, access to early treatments can improve their health" (USA Today, 1/9).
The American Cancer Society Action Network applauded the coverage as a way to help keep women healthy and reduce long-term costs. Spokesperson Steve Weiss said, "Studies show that even modest cost-sharing can keep patients from taking advantage of proven preventive tests and therapies."
Meanwhile, America's Health Insurance Plans spokesperson Robert Zirkelbach noted that while helping breast cancer patients is "a top priority for health plans," the medications are not "free," and the drugs' costs would be reflected in premium prices. He added that the group is "concerned about the precedent of expanding the definition of prevention to now include some treatments that must be covered with no cost-sharing" ("Capsules," Kaiser Health News, 1/9).