The Medicare Part D plan that patients choose greatly affects their out-of-pocket cost for cancer therapy, but not always as one might expect. Figures from a recent analysis by the American Cancer Society (ACS) and Avalere Health reveal, for example, that a patient receiving standard first-line treatment for lung cancer (non-small-cell type) could pay more than four-fold more in out-of-pocket costs depending upon the Part D plan chosen.
The information is timely, as open enrollment for Part D 2007 plans begins on November 15. ACS intends to use the data to update its primer about Part D coverage of cancer therapies. The report includes specific cost data and comparative bar graphs.
ACS and Avalere calculated and compared Medicare beneficiary out-of-pocket drug therapy costs for each of 7 standard, first-line regimens for certain cancers: breast cancer, metastatic breast cancer, metastatic colon cancer (2 different regimens), high-grade lymphoma, low-grade lymphoma, and non-small-cell lung cancer. The study considered patient costs in 12 Medicare drug plans, including 4 Medicare Advantage options. Analysts considered premiums, copays, coinsurance, and other elements of patient cost (eg, the gap in coverage referred to as the “donut hole”). It also examined Part B coverage for the same regimens.
Part D plans studied covered nearly all agents that are elements of the regimens examined. Patient cost sharing varied widely, however. Findings include the following:
- Part D plans with copays can be more costly than those using coinsurance.
- Patients reached the aforementioned coverage gap (ie, $2250 total medication spending) in only 3 protocols—those for breast cancer, metastatic breast cancer, and non-small-cell lung cancer.
- A Part D plan that offers medication coverage during the “donut hole” period usually, but not always, would substantially lower beneficiary costs for persons using the 3 aforementioned protocols that would reach the coverage gap. Examples of cases where gap coverage did not yield lower out-of-pocket costs include plans that charge relatively high copays before the gap threshold is reached, and those that exclude brand-name agents from their formularies.
- Higher-premium plans do not always result in lower out-of-pocket costs for the cases examined. Patients receiving protocols with fewer Part D drugs (eg, those for colon cancer and lymphoma) were most likely to incur higher costs with higher-premium coverage.
A key finding regarding Part B coverage is that supplemental insurance is crucial for patients receiving the treatment protocols examined in this study. Premiums for the most popular so-called Medigap plan examined varied by locality but were thousands of dollars less than the patient’s Part B liability without the insurance.
http://www.avalerehealth.net/research/docs/ACS_Cost_Sharing_For_Cancer_Patients.pdf
http://www.kaisernetwork.org/Daily_reports/rep_hpolicy.cfm#40639
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