Out-Of-Pocket Costs Can Vary Widely For Specialty Drugs In Part D

Medicare beneficiaries face wide variation in spending for specialty drugs across Part D plans, according to a new analysis.

report from GoodRx finds coverage variations between plans can lead to high out-of-pocket costs for medications, based on the top specialty medications covered under an Aetna Part D plan with more than 445,000 members. For example, the average annual out-of-pocket cost for chemotherapy drug Revlimid was $17,142, according to the report.

The minimum price paid was $2,818, and the maximum out-of-pocket for Revlimid was $20,0152, for a difference of nearly $18,000, according to the analysis.

The researchers note that in this case, the therapy is not curative, which could lead to the patient paying $15,000 or more per year on a drug that will “at best, extend their life.”

“We really wanted to pull popular specialty drugs and see what people are paying,” said Tori Marsh, director of research at GoodRx, in an interview with Fierce Healthcare. “We were pretty astonished by what we saw.”

Another concern in calculating the out-of-pocket costs for specialty drugs is the coverage phase a beneficiary is currently in. In Part D plans, patients pay fully out of pocket before they meet their deductible, reaching the initial coverage phase. After spending a certain amount of drugs during the year, they’ll reach the coverage gap, also called the Part D “donut hole.”

After clearing the coverage gap, a patient will reach catastrophic coverage.

Those impacts can be felt in the month-to-month variance in out-of-pocket costs, according to the study. Again looking at Revlimid, out-of-pocket prices for a 30-day supply ranged from $10 to $4,647 depending on the plan and which coverage phase the beneficiary was under.

Based on the cost of Revlimid, beneficiaries in the studied plan would reach the catastrophic phase in the first month and then pay 5% of the retail price monthly for the remainder of the plan year, which could lead to thousands in costs.

Part D beneficiaries should take time to shop around before selecting a plan and ensure coverage meets their needs for the medications they take. Marsh said consumers should be thinking about any specialty drug needs as being “in their own bucket” when weighing coverage options.

She said people may not be thinking about shopping around for plans each year during Medicare open enrollment, even if doing so would be beneficial.

“The first thing I would always tell people to do every year during enrollment season is type in the medications that they’re on,” Marsh said.


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