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Medicare Part D Plans Shift Costs for Biologic DMARDs

Specialty tiering places heavy burdens on poor beneficiaries with arthritis and Medicare system

THURSDAY, June 4 (HealthDay News) -- Medicare Part D plans that use specialty tiering for biologic disease-modifying antirheumatic drugs (DMARDs) may impose an intolerable financial burden on poor and disabled beneficiaries and the Medicare system itself, according to a study published in the June 15 issue of Arthritis & Rheumatism (Arthritis Care & Research).

Jennifer M. Polinksi, of Brigham and Women's Hospital in Boston, and colleagues followed 14,929 low-income rheumatoid arthritis patients who were enrolled in the Medicare Replacement Drug Demonstration, 81 percent of whom enrolled in Medicare Part D, and compared the cost-sharing provisions for biologic DMARDs in the Medicare Advantage and stand-alone plans.

Although the researchers found that Medicare Advantage plans had lower deductibles and premiums, and fewer restrictions on prior authorization, step therapy, and quantity limit than the stand-alone plans, they found that about 75 percent of all plans used coinsurance as the preferred form of cost sharing. In all of their cost-sharing scenarios, they estimated that out-of-pocket expenses for patients were higher than $4,000 per year.

"Patients assume up to 28 percent and Medicare assumes more than 58 percent of the costs of biologic DMARDs in our scenarios, yet neither is in a position to sustain such financial burden," the authors conclude. "As more biologic DMARDs are approved and used for rheumatoid arthritis and more plans use the specialty tier system, both beneficiaries and Medicare face costs they may be increasingly unable to afford."

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