The High Cost of Arthritis Treatment

A recent study examined the cost of biologic and non-biologic DMARDs under Medicare Part D and stand-alone coverage plans.

The cost of biologic disease modifying drugs (DMARDs) is nearly $2,700 annually in copayments before receiving relief from catastrophic coverage, according to research published in Arthritis & Rheumatology.

Jinoos Yazdany, MD, MPH from the University of California, San Francisco and colleagues analyzed a total of 2,737 Medicare Part D plans’ formularies across the 50 states and Washington, DC, in order to demonstrate how Part D plans cover DMARDs and patients’ financial burdens under the current cost sharing structures. The research was conducted using the January 2013 Centers for Medicare and Medicaid Services Prescription Drug Plan Formulary and Pharmacy Network Files. The researchers calculated the percentage of plans covering each DMARD, prior authorization (PA) requirements, and copayments charged. Additionally, they compared biologic drug coverage in Medicare Advantage plans to stand alone Part D plans.

The investigators examined 18 total drugs — 9 biologic medications (abatacept, adalimumab, anakinra, certolizumab, etanercept, golimumab, infliximab, rituximab, tocilizumab) and 9 non biologic DMARDs (azathioprine, cuprimine, cyclophosphamide, cyclosporine, hydroxychloroquine, leflunomide, methotrexate, minocycline, and sulfasalazine.

All plans covered at least 1 biologic DMARD, the authors found, but the majority of them (95 percent) required PAs. Almost all plans (between 81 and 100 percent) required a percentage coinsurance (about 30 percent of the drug cost) rather than a fixed dollar copayment, the researchers said. Thus, out of pocket costs were estimated as $2,712 to $2,774 before reaching the “catastrophic phase” of coverage, where beneficiaries pay about 5 percent of drug costs.

Medicare Advantage plans covered more individual biologic DMARDs (between 56 and 100 percent) when compared to the stand alone drug plans, which covered between 22 and 100 percent). The stand alone plans charged higher average coinsurance, though (31 percent vs. 29 percent, compared to the Medicare Advantage plans, respectively). The researchers additionally noted that 6 out of 9 non biologic DMARDs were covered by nearly all of the health plans without PAs at fixed copayments, which averaged between $5 and $10 per month.

“Insurance payment reforms have been suggested by the US government, but are not widely implemented in the health care system,” Yazdany explained in a press release. “With the high cost of biologic DMARDS for rheumatoid arthritis, many patients are strapped with a substantial financial burden. Americans, especially those patients with chronic conditions such as RA, may be better served by payment and drug coverage reforms that look to decrease rising out of pocket costs for patients while keeping total costs in check.”