The Out-of-Pocket Cost Burden for Specialty Drugs in Medicare Part D in 2019
| Table 1: Expected Annual Costs in Medicare Part D Plans for 30 Specialty Tier Drugs, 2019 | ||||||
| Health condition | Drug name | Full drug costs | Out-of-pocket drug costs | |||
| Off formulary | On formulary | On formulary | ||||
| Median annual total cost | Median annual total cost | Median annual out-of-pocket cost | Cost above catastrophic threshold | Percent of median cost above threshold | ||
| Cancer | Alunbrig | N/A | $187,893 | $11,014 | $8,628 | 78% |
| Calquence | N/A | $171,481 | $10,175 | $7,868 | 77% | |
| Erleada | N/A | $137,553 | $8,586 | $6,313 | 74% | |
| Gleevec | $145,787 | N/A | N/A | N/A | N/A | |
| Idhifa | N/A | $300,858 | $16,551 | $14,276 | 86% | |
| Imatinib mesylate | N/A | $91,844 | $8,983 | $3,883 | 43% | |
| Kisqali | N/A | $207,084 | $12,145 | $9,587 | 79% | |
| Nerlynx | N/A | $143,175 | $8,842 | $6,571 | 74% | |
| Revlimid | N/A | $259,051 | $14,461 | $12,186 | 84% | |
| Rubraca | N/A | $176,789 | $10,386 | $8,111 | 78% | |
| Rydapt | N/A | $206,423 | $11,830 | $9,554 | 81% | |
| Venclexta | N/A | $135,686 | $8,712 | $6,227 | 71% | |
| Verzenio | N/A | $150,126 | $9,164 | $6,889 | 75% | |
| Zejula | N/A | $202,330 | $11,625 | $9,350 | 80% | |
| Zytiga | N/A | $125,351 | $8,181 | $5,754 | 70% | |
| Hepatitis C | Epclusa | N/A | $75,538 | $5,283 | $3,010 | 57% |
| Harvoni | $113,400 | $96,732 | $6,338 | $4,063 | 64% | |
| Mavyret | $47,522 | $40,393 | $3,520 | $1,251 | 36% | |
| Sovaldi | $100,802 | $82,747 | $5,633 | $3,368 | 60% | |
| Viekira Pak | $99,985 | N/A | N/A | N/A | N/A | |
| Vosevi | $89,713 | $76,256 | $5,306 | $3,045 | 57% | |
| Zepatier | $26,210 | $22,377 | $2,622 | $351 | 13% | |
| Multiple sclerosis | Avonex | $97,799 | $85,532 | $6,507 | $3,660 | 56% |
| Copaxone | $102,456 | $89,614 | $6,672 | $3,849 | 58% | |
| Glatiramer acetate | $76,375 | $60,385 | $7,409 | $2,309 | 31% | |
| Tecfidera | $106,088 | $92,285 | $6,595 | $4,238 | 64% | |
| Rheumatoid arthritis | Enbrel | $70,171 | $60,621 | $5,465 | $2,398 | 44% |
| Humira | N/A | $59,078 | $5,471 | $2,414 | 44% | |
| Kevzara | $45,514 | $39,809 | $4,372 | $1,451 | 33% | |
| Orencia | $59,511 | $48,838 | $5,207 | $1,825 | 35% | |
| NOTE: Analysis reflects coverage and costs in 25 stand-alone prescription drug plans (mostly national/near-national), based on a pharmacy located in zip code 21201 (Baltimore, MD). ‘N/A’ is not applicable. SOURCE: KFF analysis of 2019 Medicare Plan Finder data. |
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| Table 2: Formulary Tier Placement and Utilization Management Restrictions in Medicare Part D Plans for 30 Specialty Tier Drugs, 2019 | ||||||||
| Formulary tier placement | Utilization management restrictions | |||||||
| Number of plans placing drug on: | Off formulary | Number of plans requiring: | ||||||
| Health Condition | Drug Name | Preferred brand tier | Non-preferred drug tier | Specialty tier | Prior authorization | Quantity limits | Step therapy | |
| Cancer | Alunbrig | 0 | 4 | 21 | 0 | 25 | 16 | 0 |
| Calquence | 0 | 4 | 21 | 0 | 25 | 16 | 0 | |
| Erleada | 0 | 0 | 25 | 0 | 25 | 10 | 0 | |
| Gleevec | 0 | 0 | 0 | 25 | 0 | 0 | 0 | |
| Idhifa | 0 | 0 | 25 | 0 | 25 | 16 | 0 | |
| Imatinib mesylate | 0 | 0 | 25 | 0 | 25 | 24 | 0 | |
| Kisqali | 0 | 4 | 21 | 0 | 25 | 15 | 0 | |
| Nerlynx | 0 | 0 | 25 | 0 | 25 | 11 | 0 | |
| Revlimid | 0 | 4 | 21 | 0 | 25 | 24 | 0 | |
| Rubraca | 0 | 0 | 25 | 0 | 25 | 15 | 0 | |
| Rydapt | 0 | 0 | 25 | 0 | 25 | 16 | 0 | |
| Venclexta | 0 | 7 | 18 | 0 | 25 | 14 | 0 | |
| Verzenio | 0 | 4 | 21 | 0 | 25 | 16 | 0 | |
| Zejula | 0 | 0 | 25 | 0 | 25 | 16 | 0 | |
| Zytiga | 0 | 6 | 19 | 0 | 25 | 15 | 0 | |
| Hepatitis C | Epclusa | 1 | 0 | 24 | 0 | 25 | 15 | 0 |
| Harvoni | 1 | 0 | 22 | 2 | 23 | 13 | 0 | |
| Mavyret | 0 | 0 | 15 | 10 | 15 | 6 | 0 | |
| Sovaldi | 0 | 0 | 1 | 24 | 1 | 1 | 0 | |
| Viekira Pak | 0 | 0 | 0 | 25 | 0 | 0 | 0 | |
| Vosevi | 0 | 0 | 16 | 9 | 16 | 6 | 0 | |
| Zepatier | 0 | 0 | 11 | 14 | 11 | 2 | 0 | |
| Multiple sclerosis | Avonex | 0 | 0 | 7 | 18 | 6 | 6 | 0 |
| Copaxone | 0 | 0 | 10 | 15 | 10 | 10 | 0 | |
| Glatiramer acetate | 0 | 0 | 18 | 7 | 15 | 15 | 0 | |
| Tecfidera | 0 | 0 | 13 | 12 | 11 | 8 | 0 | |
| Rheumatoid arthritis | Enbrel | 1 | 0 | 13 | 11 | 14 | 12 | 0 |
| Humira | 1 | 0 | 24 | 0 | 25 | 21 | 0 | |
| Kevzara | 0 | 0 | 3 | 22 | 3 | 3 | 0 | |
| Orencia | 0 | 0 | 5 | 20 | 5 | 0 | 0 | |
| NOTE: Analysis reflects coverage and costs in 25 stand-alone prescription drug plans (mostly national/near-national), based on a pharmacy located in zip code 21201 (Baltimore, MD). SOURCE: KFF analysis of 2019 Medicare Plan Finder data. |
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| Table 3: Expected Annual Costs in Medicare Part D Plans for 12 Specialty Tier Drugs, 2016 and 2019 | ||||||
| Health condition | Drug name | Full cost (when covered) |
Median out-of-pocket cost up to catastrophic phase | Median out-of-pocket cost in catastrophic phase | Total median out-of-pocket cost | |
| Cancer | Gleevec* | 2016 | $123,158 | $2,780 | $5,723 | $8,503 |
| 2019 | n/a | n/a | n/a | n/a | ||
| change | n/a | n/a | n/a | n/a | ||
| Revlimid | 2016 | $183,517 | $2,780 | $8,758 | $11,538 | |
| 2019 | $259,051 | $2,275 | $12,186 | $14,461 | ||
| change | $75,534 | -$505 | $3,428 | $2,923 | ||
| Zytiga | 2016 | $97,314 | $2,780 | $4,447 | $7,227 | |
| 2019 | $125,351 | $2,428 | $5,754 | $8,181 | ||
| change | $28,037 | -$352 | $1,307 | $954 | ||
| Hepatitis C | Harvoni | 2016 | $95,824 | $2,780 | $4,373 | $7,153 |
| 2019 | $96,732 | $2,275 | $4,063 | $6,338 | ||
| change | $908 | -$505 | -$310 | -$815 | ||
| Sovaldi | 2016 | $85,177 | $2,780 | $3,828 | $6,608 | |
| 2019 | $82,747 | $2,265 | $3,368 | $5,633 | ||
| change | -$2,430 | -$515 | -$460 | -$976 | ||
| Viekira Pak* | 2016 | $82,936 | $2,786 | $3,730 | $6,516 | |
| 2019 | n/a | n/a | n/a | n/a | ||
| change | n/a | n/a | n/a | n/a | ||
| Multiple sclerosis | Avonex | 2016 | $64,173 | $3,141 | $2,838 | $5,979 |
| 2019 | $85,532 | $2,847 | $3,660 | $6,507 | ||
| change | $21,359 | -$294 | $822 | $528 | ||
| Copaxone | 2016 | $73,922 | $3,143 | $3,305 | $6,448 | |
| 2019 | $89,614 | $2,823 | $3,849 | $6,672 | ||
| change | $15,692 | -$320 | $544 | $224 | ||
| Tecfidera | 2016 | $69,393 | $3,167 | $3,068 | $6,235 | |
| 2019 | $92,285 | $2,357 | $4,238 | $6,595 | ||
| change | $22,892 | -$811 | $1,170 | $360 | ||
| Rheumatoid arthritis | Enbrel | 2016 | $41,564 | $3,196 | $1,676 | $4,872 |
| 2019 | $60,621 | $3,068 | $2,398 | $5,465 | ||
| change | $19,057 | -$128 | $721 | $593 | ||
| Humira | 2016 | $42,059 | $3,155 | $1,709 | $4,864 | |
| 2019 | $59,078 | $3,057 | $2,414 | $5,471 | ||
| change | $17,019 | -$99 | $705 | $606 | ||
| Orencia | 2016 | $38,407 | $2,856 | $1,557 | $4,413 | |
| 2019 | $48,838 | $3,382 | $1,825 | $5,207 | ||
|
change |
$10,432 | $527 | $268 | $794 | ||
| NOTE: Analysis reflects coverage in 20 stand-alone prescription drug plans in 2016 and 25 stand-alone prescription drug plans (mostly national/near-national), based on a pharmacy located in zip code 21201 (Baltimore, MD). *Viekira Pak and Gleevec are not covered by any plan in our analysis in 2019. SOURCE: KFF analysis of 2016 and 2019 Medicare Plan Finder data. |
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