See Methods for additional details.) One of the seven drugs, Viekira Pak, is not covered by any of the plans in our analysis.
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The estimates in this report have been updated to reflect the recommended quantity, resulting in higher costs for Harvoni. (A previously published version of this brief reported lower costs for Harvoni, based on the default quantity in the Medicare Plan Finder (28 pills/year), which is lower than the recommended quantity (84 pills/year). Out-of-pocket spending for breakthrough therapies used to treat and cure hepatitis C represents a significant burden for Part D enrollees who do not receive low-income subsidies, even though costs for some of these drugs have fallen over time as new competitor products have come to market.Įxpected annual out-of-pocket costs in 2019 for six of the seven hepatitis C drugs in our analysis range from $2,622 for Zepatier to $6,338 for Harvoni (Figure 3). For imatinib mesylate, the generic equivalent for Gleevec, the share of costs above the catastrophic coverage threshold is lower (43%) because enrollees taking this drug do not receive a manufacturer discount in the coverage gap and therefore would incur higher out-of-pocket costs below the catastrophic coverage threshold.įigure 2: Out-of-pocket costs for Part D enrollees for selected cancer medications can exceed $8,000, with most of this spending above the catastrophic threshold Hepatitis C
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For example, 84 percent of an enrollee’s out-of-pocket costs for Revlimid, a drug to treat multiple myeloma, would occur in the catastrophic phase, which translates to $12,186 in costs for this drug in the catastrophic phase alone in 2019. Part D enrollees taking any of the brand-name cancer drugs in our analysis for the full year would pay at least 70 percent of their total annual out-of-pocket costs above the catastrophic threshold in 2019. One of the 15 cancer drugs, Gleevec, is not covered by any plan in our analysis in 2019, but the generic equivalent, imatinib mesylate, is covered by all plans, which is sufficient to meet the formulary coverage requirement that plans cover all or substantially all drugs in six so-called “protected” classes, including cancer drugs.Įxpected annual out-of-pocket costs in 2019 for the 14 covered specialty tier cancer drugs range from $8,181 for Zytiga (for prostate cancer) to $16,551 for Idhifa (for leukemia) (Figure 2). Fourteen of the 15 studied specialty tier cancer drugs are covered by all plans, and the median annual out-of-pocket cost for each of these drugs exceeds $8,000. Medicare Part D enrollees without low-income subsidies who take any of the specialty tier drugs in our analysis for various types of cancer would pay more out of pocket for these medications in 2019 than enrollees who take any of the specialty drugs for the other health conditions in this analysis. out-of-pocket Costs for SELECtED specialty tier drugs in 2019, by Condition Cancer On average across these 28 specialty drugs, 61 percent of annual out-of-pocket costs occur above the catastrophic threshold in 2019, which translates to $5,444 in out-of-pocket costs in the catastrophic phase alone. For the 28 specialty tier drugs in our analysis covered by some or all plans, the share of annual out-of-pocket costs that would be incurred in the catastrophic phase in 2019 ranges from 13 percent for Zepatier to 86 percent for Idhifa for 19 of these drugs, enrollees can expect to pay more than half of their annual out-of-pocket cost in the catastrophic phase. Part D enrollees taking high-cost specialty tier drugs often incur significant costs in the catastrophic coverage phase of the benefit because the catastrophic threshold is not an absolute limit on out-of-pocket spending. (See Tables 1 and 2 for drug-specific cost and coverage information.) Two of the 30 drugs are not covered by any plan in our analysis.
For 28 of the 30 studied specialty drugs used to treat four health conditions-cancer, hepatitis C, multiple sclerosis (MS), and rheumatoid arthritis (RA)-expected annual out-of-pocket costs for a single drug in 2019 range from $2,622 for Zepatier, a treatment for hepatitis C, to $16,551 for Idhifa, a leukemia drug. Expected annual out-of-pocket costs in 2019 average $8,109 across the 28 specialty tier drugs covered by some or all plans in this analysis. Part D enrollees can face thousands of dollars in annual out-of-pocket costs if they take expensive drugs, despite having catastrophic coverage. For many specialty tier drugs, the majority of these costs will occur in the catastrophic phase of the benefit. Medicare Part D enrollees without low income subsidies can expect to pay thousands of dollars out of pocket for a single specialty tier drug in 2019.