VBCR - June 2015, Volume 4, No 3 - Health Economics
Rosemary Frei, MSc

An analysis of 2737 Medicare Part D plans’ 2013 formularies has found that mean out-of-pocket costs for biologic disease-modifying antirheumatic drugs (DMARDs) is $2712 to $2774 before reaching the “catastrophic” phase of coverage in which beneficiaries pay only 5% of drug costs.1 Furthermore, beneficiaries with rheumatoid arthritis (RA) pay on average 29.6% coinsurance for biologic DMARD costs prior to the coverage gap.

“Many Part D beneficiaries requiring biologic DMARDs will have sufficient out-of-pocket costs to reach catastrophic thresholds in total drug spending each year. Clinicians caring for individuals with RA should be aware of this and be prepared to discuss long-term affordability as well as relative efficacy of biologic DMARDs with their patients to help them make informed decisions about treatment,” noted lead investigator Jinoos Yazdany, MD, MPH, associate professor in the Division of Rheumatology, School of Medicine, University of California San Francisco, and her coauthors in their report.

In January 2013, the team analyzed all 50 states’ and Washington DC’s Medicare Part D stand-alone prescription drug plans (PDPs) and Medicare Advantage PDPs (MA-PDPs). They did so using the Centers for Medicare and Medicaid Services’ Prescription Drug Plan Formulary and Pharmacy Network files.

Overall, 71% of the plans covered at least 1 biologic DMARD, 95% required prior approval for the various biologic DMARDs, and 95% involved beneficiary coinsurance for them. Furthermore, 95% of the plans placed biologic DMARDs in specialty tiers. The mean percentage of coinsurance for drug costs per beneficiary was 29.6%.

The mean monthly co-payment before reaching catastrophic coverage for biologic DMARDs was $835, with the lowest being $269 for infliximab and the highest being $2993 for anakinra. The mean monthly co-payment was $24 for nonbiologic DMARDs, with the highest being $114 for penicillamine.

Seventy-nine percent of MA-PDPs covered biologic DMARDs compared with 69% of PDPs. However, MA-PDPs also charged a higher percentage of coinsurance at 31.1% versus 29% for PDPs. Moreover, the mean co-payment was higher with MA-PDPs than PDPs, at $862 and $829, respectively.

Yazdany and her team also calculated the average payment by beneficiaries under a standard 2014 Part D plan for biologic DMARDs until they reached the donut hole. They found it averaged approximately $2760. This would mean that beneficiaries would reach the coverage gap by January, February, or March, depending on the biologic DMARD and the plan, and reach the catastrophic phase of coverage between January (for anakinra) and July (for infliximab), the investigators determined.

“Our findings indicate that 8 years after implementation, Part D plans continue to use high cost sharing as a primary cost-control mechanism for biologic DMARDs, placing a substantial financial burden on patients who require such drugs for adequate control of their RA symptoms,” they concluded.

These findings complement those from another study by Yazdany and her collaborators, in which they found that Medicare beneficiaries who also receive the low-income subsidy (LIS) are more likely to receive home-administered biologic DMARDs than those who do not receive the LIS.2 Non-LIS beneficiaries had lower costs for Part B facility-administered biologics than for Part D home-administered biologics. New Affordable Care Act reforms will only slightly decrease the costs for Part D biologics for non-LIS individuals, the investigators believe.

“The entire policy with respect to Medicare spending on biologic DMARDs needs to be reformed to address the cost burden the program is placing on patients,” Yazdany told Value-Based Care in Rheumatology.


  1. Yazdany J, Dudley RA, Chen R, et al. Coverage for high cost specialty drugs for rheumatoid arthritis in Medicare Part D. Arthritis Rheumatol. 2015;67(6):1474-1480.
  2. Yazdany J, Tonner C, Schmajuk G. Use and spending on biologic disease-modifying anti-rheumatic drugs for rheumatoid arthritis among U.S. Medicare beneficiaries [published online ahead of print March 16, 2015]. Arthritis Care Res. doi: 10.1002/acr.22580.
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