Cancer patients can prevent vomiting attacks after treatment with a relatively inexpensive anti-nausea pill, but for some, coverage limits increase.

Doctors say limits on the number of tablets patients can receive could harm care. Pharmacy managers say their limits prevent overuse and they offer solutions to get more tablets.

In between are patients who may have to ration pills or opt for less effective care because of a feared side effect of radiation or chemotherapy.

The conflict shows how a series of cover-ups and poor communication can complicate even simple matters. acts of care in the fragmented US health care system.

“This is kind of the dirty underbelly of the current healthcare environment,” said oncologist Dr. Fumiko Chino. “Insurance companies and pharmacy benefit managers are kind of weirdly finding themselves in my office, between me and my patients.”

Steven Manetta takes at least a half-dozen pills a day to 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 to stretch his supply. He was only recently approved for a 90-day supply.

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

Ondansetron first 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, an oncologist at the Dana-Farber Cancer Institute 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 isn’t bad either: thirty tablets of ondansetron cost less than $12 through prescription drug discount websites.

Pharmacists and doctors say they’ve been dealing with restrictions on anti-nausea drugs like ondansetron for years. Wright says she finds the restrictions “frustrating,” in part because the drug is affordable.

More than half of the plans sold on the U.S. individual insurance market impose limits on the number of ondansetron tablets patients can receive, according to preliminary results from a study by Chino and Michael Anne Kyle, a researcher at the University of Pennsylvania.

Pharmacist Yen Nguyen sees these limitations regularly, including the CVS Caremark limitations that Manetta encountered.

“With four or five months of chemotherapy, you’re fighting for pennies and nickels,” said Nguyen, director of pharmacy at the Houston-area Oncology Consultants practice.

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

“I was shocked,” said the Tehachapi, Calif., resident. “I was like, ‘Really? Have you ever had chemo?'”

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

Prime Therapeutics is limiting prescriptions of 4- and 8-milligram ondansetron to 21 tablets over 30 days. That helps provide “maximum dosing” for seven days of treatment per month, Chief Clinical Officer David Lassen said in an email.

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

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

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

Coverage limits vary, and some patients do not tell their doctors if they received a smaller amount than desired. Also, the intensity of nausea can be difficult to measure 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 as needed. But she often sees limits of 21 or 30 tablets.

“The fact that there are still limiting patterns for this very useful drug is insane,” said Chino, who recently moved from Memorial Sloan Kettering in New York to MD Anderson in Houston.

According to Dr. Ramy Sedhom, an oncologist and palliative care specialist at Penn Medicine Princeton Health, limits can be detrimental to patients who have to pay a high co-pay for each refill or have difficulty getting to the pharmacy.

“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 (their prescriptions),” he said.

If patients run out of ondansetron, even for a few days, uncontrolled vomiting can force them to go to the emergency room or stop treatment, doctors say.

Murphy, the cancer patient, has avoided all that. She said coverage for ondansetron began after her doctor at City of Hope Cancer Center asked for it.

She faces a series of chemotherapy cycles that will last well into the fall, and the treatments will leave her bedridden with nausea for days, even while taking ondansetron.

“I would hate it if I didn’t have it,” she said.

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