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

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

2024-09-10 22:57 Last Updated At:23:01

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.

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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 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)

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)

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 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)

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)

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, 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)

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 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)

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)

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)

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)

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)

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 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)

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)

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, 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)

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 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)

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)

WASHINGTON (AP) — The Senate quickly confirmed Marco Rubio as secretary of state Monday, voting unanimously to give President Donald Trump the first member of his new Cabinet on Inauguration Day.

Rubio, the Republican senator from Florida, is among the least controversial of Trump’s nominees and vote was decisive, 99-0. Another pick, John Ratcliffe for CIA director, is also expected to have a swift vote, as soon as Tuesday. Action on others, including former combat veteran and Fox News host Pete Hegseth for defense secretary, is possible later in the week.

“Marco Rubio is a very intelligent man with a remarkable understanding of American foreign policy,” Sen. Chuck Grassley of Iowa, the senior-most Republican, said as the chamber opened.

It’s often tradition for the Senate to convene immediately after the ceremonial pomp of the inauguration to begin putting the new president’s team in place, particularly the national security officials. During Trump’s first term, the Senate swiftly confirmed his defense and homeland security secretaries on day one, and President Joe Biden’s choice for director of national intelligence was confirmed on his own Inauguration Day.

With Trump’s return to the White House, and his Republican Party controlling majorities in Congress, his outsider Cabinet choices are more clearly falling into place, despite initial skepticism and opposition from both sides of the aisle.

Rubio, who was surrounded by colleagues in the Senate chamber, said afterward he feels “good, but there’s a lot of work ahead.”

“It’s an important job in an important time, and I’m honored by it,” Rubio said.

Senate Majority Leader John Thune moved quickly Monday, announcing he expected voting to begin “imminently” on Trump’s nominees.

Democrats have calculated it's better for them to be seen as more willing to work with Trump, rather than simply mounting a blockade to his nominees. They're holding their opposition for some of his other picks who have less support, including Tulsi Gabbard for director of national intelligence and vaccine skeptic Robert F. Kennedy Jr. for health secretary.

Senate Democratic Leader Chuck Schumer said his party will “neither rubber-stamp nominees we feel are grossly unqualified, nor oppose nominees that deserve serious consideration.”

Rubio, he said, is an example of "a qualified nominee we think should be confirmed quickly."

Senate committees have been holding lengthy confirmation hearings on more than a dozen of the Cabinet nominees, with more to come this week. And several panels are expected to meet late Monday to begin voting to advance the nominees to the full Senate for confirmation.

The Senate Foreign Relations Committee unanimously advanced Rubio's nomination late Monday. The Senate Armed Services Committee and Senate Intelligence Committee, respectively, voted to move the nominations of Hegseth and Ratcliffe. And the Homeland Security and Government Affairs Committee advanced nominees Kristi Noem as homeland security secretary and Russell Vought as director of the Office of Management and Budget, but with opposition.

Rubio, a well-liked senator and former Trump rival during the 2016 presidential race, has drawn closer to the president in recent years. He appeared last week to answer questions before the Foreign Relations Committee, where he has spent more than a decade as a member.

As secretary of state, Rubio would be the nation’s top diplomat, and the first Latino to hold the position. Born in Miami to Cuban immigrants, he has long been involved in foreign affairs, particularly in South America, and has emerged as a hawk on China’s rise.

During his confirmation hearing last week, Rubio warned of the consequences of America’s “unbalanced relationship” with China. While he echoes Trump’s anti-globalist rhetoric, Rubio is also seen as an internationalist who understands the power of U.S. involvement on the global stage.

Rubio cultivated bipartisan support from across the aisle, both Republicans and Democrats. He takes over for outgoing Secretary of State Antony Blinken, who has said he hopes the Trump administration continues Biden's policies in the Middle East to end the war in Gaza and to help Ukraine counter Russian nomination.

The Senate is split 53-47, but the resignation of Vice President JD Vance and, soon, Rubio drops the GOP majority further until their successors arrive. Republicans need almost all every party member in line to overcome Democratic opposition to nominees.

Objection from any one senator, as is expected with Hegseth and several other choices, would force the Senate into procedural steps that would drag voting later into the week.

Associated Press writers Farnoush Amiri and Mary Clare Jalonick contributed to this report.

President-elect Donald Trump's Cabinet picks, other nominees and appointments, pose for a photo at the National Gallery of Art in Washington, Saturday, Jan. 18, 2025. First row from left, Elise Stefanik, John Ratcliffe, Lori Chavez-DeRemer, Howard Lutnick, Pete Hegseth, Doug Burgum, Brooke L. Rollins, Marco Rubio and Robert F. Kennedy Jr.; second row from left, Scott Turner, Tulsi Gabbard, Sean Duffy, Linda McMahon, Lee Zeldin, Kristi Noem, Chris Wright, Doug Collins, Kelly Loeffler and Scott Bessent; and third row from left, Stephen Miran, Jamieson Greer, Kevin Hassett, Kash Patel and Russell Vought. (AP Photo/Mark Schiefelbein)

President-elect Donald Trump's Cabinet picks, other nominees and appointments, pose for a photo at the National Gallery of Art in Washington, Saturday, Jan. 18, 2025. First row from left, Elise Stefanik, John Ratcliffe, Lori Chavez-DeRemer, Howard Lutnick, Pete Hegseth, Doug Burgum, Brooke L. Rollins, Marco Rubio and Robert F. Kennedy Jr.; second row from left, Scott Turner, Tulsi Gabbard, Sean Duffy, Linda McMahon, Lee Zeldin, Kristi Noem, Chris Wright, Doug Collins, Kelly Loeffler and Scott Bessent; and third row from left, Stephen Miran, Jamieson Greer, Kevin Hassett, Kash Patel and Russell Vought. (AP Photo/Mark Schiefelbein)

Sen. Marco Rubio, R-Fla., a nominee for Secretary of State, attends the 60th Presidential Inauguration in the Rotunda of the U.S. Capitol in Washington, Monday, Jan. 20, 2025. (Kevin Lamarque/Pool Photo via AP)

Sen. Marco Rubio, R-Fla., a nominee for Secretary of State, attends the 60th Presidential Inauguration in the Rotunda of the U.S. Capitol in Washington, Monday, Jan. 20, 2025. (Kevin Lamarque/Pool Photo via AP)

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