Medicare policies must set cost sharing under Part D, expert writes

A Vanderbilt University health policy researcher calls for modernizing Medicare policies to control or cap out-of-pocket spending for seniors as more expensive cancer drugs are managed under the Part D program.

Stacie B. Dusetzina, PhD, who is the Ingram Associate Professor of Cancer Research at Vanderbilt University Medical Center, addresses this topic in an essay, “Your Money or Your Life – The High Cost of Cancer Drugs Under Medicare Part D,” published today in the New England Journal of Medicine.

Dusetzina, who is also a member of the editorial board of The American Journal of Managed Care®, writes that up to half of all cancer drugs are now delivered as oral agents, meaning they are no longer billed as a medical benefit, but rather as a drug benefit under Medicare Part D. Although Dusetzina does not address this directly, there have been reports that the use of oral oncolytics has increased during the pandemic as physicians seek to reduce cancer patients’ risk of exposure to COVID-19.

For younger patients, notes Dusetzina, the increased use of oral cancer agents might not be noticeable. But this change is very important for older patients because of Medicare cost-sharing rules — and older patients are more likely to develop cancer. “Most beneficiaries would be responsible for high (and unlimited) out-of-pocket expenses for drugs filled as part of their pharmacy benefit,” or Part D.

These same seniors have typically taken steps to protect against unexpected medical expenses under Medicare Part B, as 90% have additional coverage to cover most out-of-pocket expenses under the medical benefit. But it’s not a help with drug benefits.

Dusetzina illustrates the problem by comparing 2 first-line treatment scenarios for patients with common types of newly diagnosed metastatic breast cancer:

  • A patient with HR+, HER2-negative cancer may be prescribed 2 oral medications: an aromatase inhibitor and a CDK4/6 inhibitor. Although aromatase inhibitors are now available in generic form, CDK4/6 inhibitors are new and the listed cost was $3,100 for the first fill, with over $10,500 for 1 year of use, if the patient has not done so. quality for low-income grants.
  • By comparison, a patient with HER2-positive cancer would receive a combination of trastuzumab, pertuzumab and a taxane. Because these drugs are administered by a physician, they are covered by the patient’s medical benefit. “For beneficiaries with supplemental coverage, drugs would be subject to a spending limit or would be covered with limited or no cost sharing,” Dusetzina writes.

She notes that in both scenarios, patients received the current standard of care, with each physician prescribing based on the patient’s breast cancer subtype. But a patient would face much higher out-of-pocket expenses because the most appropriate treatment happens to be an oral agent.

The cost-sharing rules in Medicare Part D, she writes, should be considered in light of typical seniors’ incomes, which may be quite low, although incomes may not be low enough to qualify for subsidies. .

The patient prescribed the CDK4/6 inhibitor, for example, could pay half her annual income for that drug alone, writes Dusetzina, “not counting bonuses and other necessary medical care. Asset limits, including retirement savings and investment limits, may further limit access to subsidies among older adults.

Medicare Part D reimbursable spending limits, or policies that would spread the cost of the initial fill over 12 months could make a difference for patients with limited incomes, she writes. The Center for Medicare and Medicaid Innovation could be encouraged to test other models such as monthly price caps.

Dusetzina made her argument in light of President Joe Biden’s recent unveiling of Moonshot 2.0, which calls for a 50% reduction in cancer death rates in the United States over the next 25 years. To do this, Dusetzina writes, patients must be able to pay for their medications.

“Ensuring access to prescription drugs with proven benefits and limiting the amount patients pay out of pocket would be an important first step,” she concluded. “Without access, even remedies are ineffective.”


Dusetzina S. Your money or your life – the high cost of cancer drugs under Medicare Part D. N English J med. Published online May 4, 2022. DOI: 10.1056/NEJMp2202726

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