Prescription Drug Benefits For Medicare Patients With Cancer To Cost More In 2009

Main Category: Medicare / Medicaid / SCHIP
Also Included In: Pharmacy / Pharmacist
Article Date: 13 Dec 2008 - 1:00 PDT

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People with cancer enrolled in Medicare Part D plans will spend more out-of-pocket for their Part D drugs and face increased restrictions on access to them in 2009, according to new research released by Avalere Health and the American Cancer Society Cancer Action Network (ACS CAN).

The Avalere-ACS CAN research found that Medicare stand-alone prescription drug plans (PDPs) have been increasingly shifting name-brand oral cancer drugs to higher formulary tiers over the last four years, meaning that with each year, the products have cost more for consumers.

In 2009, the large majority of PDPs placed name-brand oral oncology products -- including Gleevec, Sutent, Tarceva, Thalomid, and Tykerb -- on specialty tiers that require cost sharing of 26 percent to 35 percent for each prescription. For example, 84 percent of PDP enrollees are in plans that put Gleevec -- a name-brand drug used to treat leukemia and other forms of cancer -- on their most expensive tiers (fourth or higher) in 2009, up from 39 percent in 2006.

"This pattern of shifting the costs of branded medications to patients needs to be scrutinized, especially in light of the economic difficulty being experienced by so many seniors," said Valerie Barton, a vice president at Avalere Health.

"Shifts in drug coverage can limit access to treatment for people with cancer, significantly reducing their treatment options or even requiring a stoppage of treatment," said Daniel E. Smith, president of ACS CAN. "We urge policymakers to pay close attention to how these changes impact people with cancer. At the same time, it is critical that people with cancer understand their health coverage and the potential hurdles that may impact their treatment."

In addition to changing tier placement, PDPs in 2009 are increasing their use of prior authorization to control access to branded cancer drugs. The Avalere-ACS CAN research found that Gleevec had the largest increase in the number of PDPs requiring prior authorization, with 70 percent of plans requiring it, up from 35 percent in 2006. Tarceva had the next highest increase, with 62 percent of plans requiring prior authorization in 2009, up from 35 percent in 2006. Thalomid was next, with 68 percent of plans requiring prior authorization in 2009, up from 43 percent in 2006.

Geography and plan choice influence how much a person with cancer will spend out-of-pocket in Medicare Part D. Avalere and ACS CAN modeled hypothetical drug regimens for women with breast cancer and found that total out-of-pocket costs for a woman enrolled in AARP MedicareRx Saver in Florida will be about $1,985, while total out-of-pocket costs for beneficiaries enrolled in Humana PDP Standard in California will average about $2,551.

ACS CAN and the American Cancer Society are closely monitoring these issues as part of their nationwide efforts to ensure access to quality, affordable health care for all Americans. The organizations believe that the health care system needs to be retooled with an emphasis on prevention and early detection; meaningful health insurance that is adequate, affordable, available and administratively simple; and reducing pain and suffering with an emphasis on quality of life.

Avalere continues to analyze Medicare drug benefit data. Since the inception of the Medicare drug program, Avalere has used its proprietary DataFrame(R) database to track trends in drug pricing, plan strategy and structure, and the beneficiary experience.

ACS CAN, the nonprofit, nonpartisan advocacy affiliate of the American Cancer Society, supports evidence-based policy and legislative solutions designed to eliminate cancer as a major health problem. ACS CAN works to encourage elected officials and candidates to make cancer a top national priority. ACS CAN gives ordinary people extraordinary power to fight cancer with the training and tools they need to make their voices heard. For more information, visit http://www.acscan.org.

Avalere Health is a leading advisory company focused on business strategy and public policy. It serves a diverse client base, which includes Fortune 500 healthcare technology companies, federal government agencies, and major medical foundations. The company is organized into seven substantive areas -- Medicare, Medicaid, Reimbursement, Long-Term and Post-Acute Care, Health Information Exchange, Evidence-Based Medicine, and Education. Anchored by a comprehensive research engine and staffed by experts in business, medical product commercialization, and health policy, Avalere provides strategic guidance, objective analytic research, and quality educational programs focused on the full range of healthcare issues facing our nation. Further information can be obtained at http://www.avalerehealth.net.

Avalere Health
http://www.avalerehealth.net