Really wonderful information to use fighting insurance co. denial of off-label drug
Q&A: Off-Label Drugs
What is off-label use?
Why is off-label use of drugs so common in cancer treatment?
Can off-label drug use be harmful?
Will my health insurance cover drugs used off label for cancer treatment?
What questions should I ask my doctor about off-label drug use?
What states require insurance coverage of off-label cancer drugs?
What is off-label use?
Off-label use refers to the use of an approved treatment for any purpose, or in any manner, other than what is described in the treatment's labeling. Off-label use of an approved treatment is not the same as expanded access or special exemption, which are mechanisms allowing patient access to investigational treatments not yet approved by the FDA. (See Access to Investigational Drugs: Questions and Answers for more information.)
New treatments can be legally marketed in the United States only after approval by the U.S. Food and Drug Administration (FDA). Approval is the final stage of a multi-year process of study and testing to establish that the new treatment is safe and effective for the proposed use. (The FDA maintains a searchable database of approved cancer drugs, complete with labeling information.)
A cancer treatment rarely receives approval for general use against cancer. Instead, a treatment is approved for use in treating a specific stage of a particular kind of cancer, for which it has been tested in patients. The specific approved use is called an indication. The indication is described in the labeling for the drug or biologic, which consists of a printed insert included in the treatment's packaging. The insert also describes in detail the chemical composition of the treatment, how it works in the body, and the possible adverse effects of taking it.
However, the FDA - although responsible for ensuring that a treatment is safe and effective for the specific approved indication - does not regulate the practice of medicine. This means that once the FDA approves a treatment, licensed physicians can prescribe it for any purpose they consider medically appropriate.
Off-label uses may include giving an approved treatment:
for a disease other than the disease it is approved for,
at a different dose or frequency than specified in the product's labeling, or
to treat a child when the product is approved to treat adults.
An off-label use of a product can cease to be off label if the product's maker submits a supplemental application and obtains FDA approval for the new use. The FDA encourages, but does not require, drug makers to do this.
To submit a supplemental application, the drug maker must conduct studies to show that the product is safe and effective for the proposed new use. Unless the drug company expects to gain a significant commercial benefit from expanded approval of a drug already on the market, it may decide not to invest time and money in such additional studies.
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Why is off-label use of drugs so common in cancer treatment?
A 1991 study by the U.S. General Accounting Office found that one-third of the drug treatments performed by cancer doctors were off-label; more than half of cancer patients received at least one drug for an off-label indication. A 1997 survey of 200 cancer doctors by the American Enterprise Institute and the American Cancer Society found that 60 percent of them prescribed drugs off-label. Frequently the standard of care for a particular type or stage of cancer involves the off-label use of one or more drugs.
Off-label use of drugs is widespread in cancer treatment for several reasons.
Some cancer drugs are found to be effective against a variety of tumor types.
The mechanism of action of a drug or biologic (the way it works in the body) often suggests that it might be effective against tumor types other than those for which it is approved.
For example, cisplatin (brand name, Platinol®) works to halt the uncontrolled growth of cancer cells by interrupting the copying of DNA in growing cells. Because uncontrolled cell growth is part of most cancers, cisplatin is often used in the treatment of thyroid and lung cancers although it is only approved to treat bladder, testicular and ovarian cancers.
Some cancer drugs are approved because they effectively act on a specific biological target present in a particular type of tumor. Examples of such targeted drugs include:
imatinib mesylate or STI571 (brand name Gleevec™), which blocks the bcr-abl protein in chronic myelogenous leukemia,
trastuzumab (brand name Herceptin®), which blocks the HER 2 protein in breast cancer, and
tamoxifen (brand name Nolvadex®), which blocks the estrogen receptor in breast cancer.
However, once a drug is on the market further research may show that it also acts on different biological targets present in other kinds of cancer. Doctors may then begin to use the drug off label to treat those other cancers.
Cancer chemotherapy often involves the use of multiple drugs.
Multiple-drug treatment regimens have been shown to be effective in several types of cancer, including lymphoma, leukemia, bladder, testicular, and breast cancer. The regimens might include one or more drugs not approved specifically for that disease. Also, the FDA generally does not approve multidrug regimens themselves, in part because such regimens are so numerous as to make separate approvals impractical. Multidrug regimens change over time as doctors try different combinations and observe which regimens seem to produce the greatest benefit for patients.
Cancer treatment is always evolving.
Researchers continually conduct studies to determine new uses for already marketed drugs and to find effective combinations of drugs for new indications. The results of these studies are published in peer-reviewed medical journals. When a new treatment approach seems to produce better outcomes for patients, other doctors adopt it and it may become a new standard of care.
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Can off-label drug use be harmful?
Use of a drug off label may cause harm when the drug's effect against a kind of cancer has not been demonstrated and there is no medical reason to believe the drug might be an effective treatment for that kind of cancer. All drugs have side effects; the side effects of cancer drugs vary depending on the kind of cancer being treated. When a drug's effect against a type of cancer has not been demonstrated, and its side effects are unknown, the possible risks of giving the drug may outweigh the possible benefits.
For example, the FDA approved the use of Gleevec to treat chronic myelogenous leukemia (CML). However, as of November 2001, its effect against chronic lymphocytic leukemia (CLL) had not been studied. The biological process that leads to the development of CLL is quite different from that which causes CML. Currently, there is little scientific data to support using Gleevec to treat CLL. Furthermore, it is not known what side effects the drug might cause in patients with CLL. For these reasons, the off-label use of Gleevec to treat CLL is generally not advised.
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Will my health insurance cover drugs used off label for cancer treatment?
Some managed care organizations and health insurance providers decline to reimburse the cost of drugs used off label to treat cancer. Some insurers argue that when a drug is used for an unapproved indication, the use is experimental and therefore, excluded from coverage.
However, because changes frequently occur in the standard of care for cancer treatment, some insurance providers may be unaware of new combination drug regimens or new uses for approved drugs. In some cases, insurers may attempt to limit a doctor's choice of drugs to those that are lower in cost.
Since drugs used off label are often the standard of care for a particular kind of cancer, insurers' denial of coverage for such treatment means that patients may not receive what their doctors consider the best available treatment for their disease. To address this problem, federal and state lawmakers have passed laws that require coverage of off-label drug use for cancer treatment when the use is documented in certain authoritative drug reference books or in the medical literature.
The U.S. Congress passed a law in 1993 requiring Medicare (
http://www.medicare.gov/), the federally funded health care program for elderly and disabled people, to cover off-label drugs used in cancer treatment when the use is supported by:
a citation in at least one of the following authoritative drug reference books.
The American Society of Health-System Pharmacists' American Hospital Formulary Service (AHFS). There is a regularly updated online version.
U.S. Pharmacopeia Drug Information
two or more peer-reviewed articles published in respected medical journals.
Medicare coverage policy is not binding on private health insurance providers, although some insurers have adopted coverage policies consistent with Medicare's. Many states (see below) have passed laws or issued regulations requiring state-regulated private health insurers to provide coverage similar to Medicare's for off-label drug use in cancer treatment. However, organizations (usually large companies) funding their own health insurance coverage are exempt from these state laws and regulations, although many comply voluntarily.
The complexity of the laws and regulations governing health insurance coverage means there is no simple answer to the question of whether your own health plan covers drugs used off label for cancer treatment. When considering off-label drug use, you and your doctor should carefully check your plan's coverage policy.
If coverage is initially denied, it may be helpful for the doctor to provide the insurer with copies of peer-reviewed journal articles or other documents supporting the proposed off-label use.
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What questions should I ask my doctor about off-label drug use?
The following are some questions you may wish to ask your doctor about off-label drug use in cancer treatment.
What evidence is there to support the off-label use of this drug to treat the type of cancer that I have?
Is the off-label use of this drug likely to be more effective that the use of an approved drug?
What are the risks and benefits of off-label treatment with this drug?
Will my health insurance cover off-label treatment with this drug?
If my treatment involves a multidrug regimen and one of the drugs is being used off label, will my health insurance cover it?
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What states require insurance coverage of off-label cancer drugs?
As of November 2001, the following states required some state-regulated health insurance providers to cover the off-label use of FDA-approved drugs for cancer treatment. Except where indicated, state law requires the coverage.
Although the wording of these laws varies from state to state, most require off-label uses to be covered when documented in authoritative drug reference books. Many, but not all, laws also require coverage when an off-label use is documented in the peer-reviewed medical literature.
Source: Association of Community Cancer Centers
* Non-legislative agreement with insurance providers
# Administrative rule with force of law
Alabama Missouri
Arizona Nebraska
Arkansas Nevada
California New Hampshire
Colorado New Jersey
Connecticut New Mexico#
Florida New York
Georgia North Carolina
Hawaii* North Dakota
Illinois Ohio
Indiana Oklahoma
Kansas Oregon
Kentucky Rhode Island
Louisiana South Carolina
Maine South Dakota
Maryland Tennessee
Massachusetts Texas
Michigan Virginia
Minnesota Washington#
Mississippi
Hope this helps!
Lani
Outraged at off the label cost of Herceptin
Herceptin Costs
Thank you Robin
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