Biologic High Out of Pocket Costs for Medicare Patients Save

Specialty tier drugs, including biologics, accounts for nearly half of all medication spending by Medicare Part D patients. High out-of-pocket costs for these patients is a major concern. 

A new Kaiser Family Foundation analysis examined the high out-of-pocket cost burden for Medicare enrollees taking specialty medications. For the majority of these medications, costs will occur above the catastrophic threshold, translating to $5444 in out-of-pocket costs in the catastrophic phase alone.

Specialty drugs account for nearly half of overall medicine spending and amount to more than 20% of total Part D spending.

They specifically calculated the expected annual 2019 out-of-pocket costs for 30 specialty tier drugs across 4 conditions: hepatitis C virus (HCV), multiple sclerosis (MS), cancer, and rheumatoid arthritis (RA). 

• The annual out-of-pocket costs are expected to be higher in 2019 on average for 8 of the 10 specialty drugs (compared with 2016).
• For 28 of the 30 specialty drugs covered by some or all plans, out-of-pocket costs in 2019 will average $8109.
• Coverage varied widely for many of these specialty medications, reflecting a broad spectrum of out-of-pocket costs across the 4 conditions and 28 specialty tier drugs analyzed.
• Patients taking cancer medications are most likely to face higher out-of-pocket costs in 2019 than other diseases, with out-of-pocket costs exceeding $8000, most of this spending is above the catastrophic threshold. 
• Expected annual out-of-pocket costs for HCV medications exceed $2000, with the highest at $6338 for Harvoni.
• Expected annual out-of-pocket costs in 2019 for MS range from $6507 for Avonex to $7409 for glatiramer acetate.
• Expected annual out-of-pocket costs in 2019 for RA range from $4372 for Kevzara to $5471 for Humira.
• For specialty tier drugs that are not covered, the authors estimated annual costs in Part D are at least 10 times higher than when covered.

Cubanski J, Koma W, Neuman T. The Out-of-Pocket Cost Burden for Specialty Drugs in Medicare Part D in 2019. Kaiser Family Foundation. 2019.