Limits to anti-nausea pill coverage wear on cancer patients and doctors

Cancer patients can ward off waves of vomiting after treatment with a relatively cheap anti-nausea pill, but some are running into coverage limits.

Doctors say restrictions on the number of tablets patients receive can hurt care. Pharmacy benefit managers say their limits guard against overuse, and they offer workarounds to get more tablets.

In between sit patients, who might ration pills or opt for less effective help for a dreaded side effect of radiation or chemotherapy.

The conflict shows how an array of coverages and poor communication can complicate even simple acts of care in the fragmented U.S. health care system.

“This is sort of the dirty underbelly of the current health care environment,” said oncologist Dr. Fumiko Chino. “Insurance companies and pharmacy benefit managers are somehow weirdly ending up in my exam room, standing between me and my patients.”

Steven Manetta takes at least a half dozen pills daily to help keep a form of leukemia in remission. For more than a year, he rationed his go-to anti-nausea pill, ondansetron, known by the brand-name Zofran.

Manetta’s coverage through CVS Caremark paid for 18 ondansetron pills every 21 days. That forced him to sometimes use alternatives that make him extremely drowsy in order to stretch his supply. He only recently got approval for a 90-day supply.

“It’s just like an extra thing to think about all the time,” the 33-year-old Lemont, Illinois, resident said. “When you’re on so many medications, the ones with the least side effects are the ones you always want to reach for.”

Ondansetron hit the U.S. market more than 30 years ago. It was the first in a series of drugs that gave doctors a better way to control nausea and vomiting, said Dr. Alexi Wright, a Dana-Farber Cancer Institute oncologist who teaches at Harvard.

Wright and other cancer specialists call ondansetron a cornerstone treatment because of its relative safety, effectiveness and limited side effects.

The price doesn’t hurt either: Thirty tablets of ondansetron can cost under $12 through prescription discount websites.

Pharmacists and doctors say they've dealt with restrictions on anti-nausea drugs like ondansetron for years. Wright says she finds the limits “infuriating” in part because the drug is affordable.

More than half the plans sold on the U.S. individual insurance marketplace limit the number of ondansetron tablets that patients can get, according to preliminary results from a study by Chino and Michael Anne Kyle, a University of Pennsylvania researcher.

Pharmacist Yen Nguyen frequently sees these restrictions, including the limits from CVS Caremark that Manetta encountered.

“Over four or five months of chemotherapy, you’re fighting for dimes and nickels here," said Nguyen, executive director of pharmacy for the Houston-area practice Oncology Consultants.

Jennette Murphy paid cash for ondansetron when her cancer treatment started earlier this year because she couldn't get coverage for the amount her doctor requested. Then she got a letter telling her the drug wouldn't be covered.

“It freaked me out,” the Tehachapi, California, resident said. “I’m like, ‘Really? Have you ever been through chemo?’”

Pharmacy benefit managers say they set limits based partly on the treatment and offer several ways for doctors to request more.

Prime Therapeutics limits 4- and 8-milligram prescriptions of ondansetron to 21 tablets over 30 days. That helps provide “maximum dosing” for seven days of treatment a month, chief clinical officer David Lassen said in an email.

He said quantity limits are approved by independent doctors and pharmacists. They help prevent waste and excessive use that may not be safe.

CVS Caremark spokesman Mike DeAngelis said his company bases limits on Food and Drug Administration guidelines. He added that the company can make a decision on requests for more tablets in less than 24 hours.

Doctors say they don't always know when patients will need more.

Coverage limits vary, and some patients may not tell their doctor that they got a smaller-than-desired amount. Also, nausea intensity can be hard to gauge with newer treatments.

Chino says she wants patients to start with 90 tablets of ondansetron, enough to take the drug three times a day for a month if needed. But she often sees limits of 21 or 30 tablets.

“The fact that there’s still restrictive patterns on this very useful medication is insane,” said Chino, who recently moved from Memorial Sloan Kettering in New York to MD Anderson in Houston.

Limits can hurt patients who have big copayments for each refill or trouble getting to the drugstore, noted Dr. Ramy Sedhom, an oncologist and palliative care specialist with Penn Medicine Princeton Health.

“I have a lot of patients who only go to the pharmacy once a month when their niece or nephew is in town to pick up the (prescriptions),” he said.

If patients run out of ondansetron, even for a few days, uncontrolled vomiting can send them to emergency rooms or force a treatment pause, doctors say.

Murphy, the cancer patient, has avoided all of that. She said coverage started for ondansetron after her City of Hope cancer center doctor requested it.

She faces a stretch of chemotherapy cycles that will extend well into the fall. The treatments leave her bedridden for days with nausea even while taking ondansetron.

“I would hate to not have it,” she said.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

Cancer patient Steven Manetta sits for a portrait Monday, Sept. 9, 2024, in his Lemont, Ill., home with four of the five medicines he takes daily to battle the nausea from his chemotherapy. (AP Photo/Charles Rex Arbogast)

Steve and Julia Manetta take their dog Basil for a walk after dinner Thursday, Aug. 29, 2024, in Lemont, Ill. (AP Photo/Charles Rex Arbogast)

An entry in a journal that Julia Manetta wrote as part of her wedding vows to her husband, Steven, that addresses his cancer treatment Thursday, Aug. 29, 2024, is seen at their Lemont, Ill., home. (AP Photo/Charles Rex Arbogast)

Julia and Steven Manetta eat dinner as their dog, Basil, watches closely Thursday, Aug. 29, 2024, in their Lemont, Ill., home. (AP Photo/Charles Rex Arbogast)

Julia Manetta feeds Basil a piece of watermelon as she and her husband, Steven, prepare dinner Thursday, Aug. 29, 2024, in their Lemont, Ill., home. (AP Photo/Charles Rex Arbogast)

Steven Manetta, a cancer patient, returns from the garden with an eggplant for dinner as his dog Basil leads him up the stairs at his home in Lemont, Ill., Thursday, Aug. 29, 2024. (AP Photo/Charles Rex Arbogast)

Julia Manetta, left, and her husband, Steven Manetta, a cancer patient, work on dinner Thursday, Aug. 29, 2024, in their Lemont, Ill., home. (AP Photo/Charles Rex Arbogast)

Julia Manetta applies an anti-nausea patch on the neck of her husband, Steven, a cancer patient, Thursday, Aug. 29, 2024, in their Lemont, Ill., home. (AP Photo/Charles Rex Arbogast)

Cancer patient Steven Manetta sits for a portrait Monday, Sept. 9, 2024, in his Lemont, Ill., home with four of the five medicines he takes daily to battle the nausea from his chemotherapy. (AP Photo/Charles Rex Arbogast)

Cancer patient Steven Manetta sits for a portrait Thursday, Aug. 29, 2024, in his Lemont, Ill., home. Manetta takes at least a dozen pills daily to keep a form of the blood cancer leukemia in remission. (AP Photo/Charles Rex Arbogast)

Sidney Crosby and Leon Draisaitl have their contract extensions, Paul Maurice and the Florida Panthers have the Stanley Cup and a brief but busy summer of moving and shaking is over.

Now, back to hockey.

Less than 90 days since the Panthers beat the Edmonton Oilers in Game 7 of a thrilling final, training camps open around the league this week with plenty of questions before the puck drops next month on another season.

Boston goaltender Jeremy Swayman is the most prominent player left unsigned, camp in Columbus goes on in sorrow after the tragic death of Johnny Gaudreau and players and staff in Utah get a fresh start after the Coyotes relocated from Arizona to Salt Lake City. Colorado captain Gabriel Landeskog may be back, Washington winger T.J. Oshie may be gone and it's anyone's guess who will lift the Cup in June.

The Bruins traded 2023 Vezina Trophy-winning goalie Linus Ullmark to Ottawa, content to give the starting job to Swayman. One problem? He's a restricted free agent without a contract for the season.

“Those things just kind of sort themselves out as they do,” said teammate Brandon Carlo, who pointed to his own late arrival and that of fellow defenseman Charlie McAvoy in recent years as reasons not to be worried. “We have a lot of faith within our organization, in our management, to get the right deal done.”

Swayman, who turns 26 in late November, ranked fifth in the NHL with a .916 save percentage and eighth with a 2.53 goals-against average last season. He was being paid a team-friendly $3.475 million on a one-year contract and will get a raise — but how much and for how long?

“It’s obviously a balance of going back and forth,” Carlo said. “But I’ve had some conversations with Sway. He seems pretty encouraged and in a good mindset with it all, so as long as he’s feeling OK mentally, that’s all we really care about.”

Among the other unsigned players are Detroit's Moritz Seider two years removed from being rookie of the year, Dallas defenseman Thomas Harley and New Jersey forward Dawson Mercer. The Red Wings signed Lucas Raymond to a $64 million, eight-year contract Monday.

The Blue Jackets are getting back on the ice mere weeks after Johnny Gaudreau and younger brother Matthew died when they were struck by a driver of an SUV while riding bicycles on the eve of their sister's wedding. A candlelight vigil was held outside the arena in Columbus, players and team employees attended the tearful funeral and playing hockey was the furthest thing from anyone's mind.

Captain Boone Jenner and general manager Don Waddell hope the rink will serve as a refuge of sorts.

“We both agreed the quicker we can get guys back in the room together, the better it would be for everybody,” Waddell said. “We all mourn and heal differently, but I think as a team, being together like that is going to be critical for them to get moving forward.”

This is the team's second camp in recent years that follows the offseason death of a player. Goaltender Matiss Kivlenieks died in July 2021 of chest trauma from an errant fireworks mortar blast at the wedding of an assistant coach's daughter.

This will be the 45th training camp for the organization that was once the original Winnipeg Jets, then the Phoenix Coyotes and until earlier this year the Arizona Coyotes. It's the first and only season as the Utah Hockey Club after a move from the desert to Salt Lake City.

Ryan and Ashley Smith's Smith Entertainment Group now owns the team, keeping the same hockey operations staff, coaches, players and prospects but starting over with a clean slate in the record books like an expansion franchise.

“It’s a once-in-a-lifetime opportunity to play with a new organization," said Josh Doan, who's now with Utah after making his NHL debut with the team dad Shane captained for much of his career. “But to do it with all the guys you’ve been with and the people that you’re close with already is something that’s fun to do.”

Utah, which is expected to get permanent name and logo after the season, plays its first game Oct. 8 against Chicago at the downtown Delta Center, the home of the NBA's Jazz.

Six-time 30-goal scorer Max Pacioretty is the biggest player attending camp on a professional tryout agreement. Pacioretty is in Toronto, and agent Allan Walsh has said he expects the 35-year-old winger to sign a contract prior to the start of the season.

Others with the opportunity to earn a deal include Travis Dermott with defending Western Conference champion Edmonton; fellow defenseman Tyson Barrie with Calgary; 2020 and '21 Cup winner Tyler Johnson with Boston; and respected veteran forward Pierre-Edouard Bellemare with Colorado. Longtime New York Islanders enforcer Matt Martin is also back, hoping to stick around and get another contract.

Landeskog's next game will be his first in the NHL since lifting the Stanley Cup over his head when the Avalanche defeated the Lightning in Game 6 of the final in 2022. A nagging right knee injury and subsequent cartilage replacement surgery to attempt to fix the problem have cost the Swedish forward the past two seasons.

“Seeing him around the rink, obviously being more active on the ice, seeing the progressions he’s made from when we were here for playoffs previously, it’s awesome to see,” forward Logan O'Connor said.

Oshie has played through chronic back problems for years and said after Washington lost in the first round of the playoffs he would only return if he and doctors could come up with a solution that keeps him in the lineup. The Capitals seem to have prepared for life without Oshie, but it is not clear if the 37-year-old who was part of their 2018 Cup run intends to try to keep playing.

AP Hockey Writer John Wawrow, AP Sports Writer Pat Graham and AP freelance writer W.G. Ramirez contributed.

AP NHL: https://apnews.com/hub/nhl

Columbus Blue Jackets line up at their blue line for the national anthem with Boston Bruins before the Sabres Prospects Challenge hockey game in Buffalo, N.Y., Saturday, Sept. 14, 2024. (AP Photo/John Wawrow)

FILE - Boston Bruins' Jeremy Swayman makes a glove save during the third period in Game 6 of an NHL hockey Stanley Cup second-round playoff series against the Florida Panthers, May 17, 2024, in Boston. (AP Photo/Michael Dwyer, File)