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Patients Grapple With High Cost of Arthritis Medications

Ninety-five percent of plans require prior authorization for DMARDs

The first national investigation of Medicare coverage of biologic disease-modifying drugs (DMARDs) has found that in starting a single biologic DMARD, patients face more than $2,700 in copayments each year before receiving relief from catastrophic coverage.

Results published in Arthritis & Rheumatology show that during the initial phase of coverage, most people are expected to pay 30% of total biologic drugs costs out-of-pocket, creating a significant financial burden for patients with chronic rheumatic diseases, such as rheumatoid arthritis (RA).

RA is a chronic autoimmune disease affecting 1.3 million Americans. Medical evidence shows that until the late 1990s, one in three RA patients was permanently disabled within 5 years of disease onset. During the last decade, there has been significant improvement in treatment, with disease control now possible for many RA patients who receive early, aggressive DMARD therapy.

Treatment with DMARDs is now a standard component of guideline-based RA care, with costs for some of the newer drugs topping $20,000 annually. A recent report by GBI Research estimates that the U.S. market for RA treatment will increase from $6.4 billion in 2013 to $9.3 billion by 2020, driven in part by the increase in RA prevalence — forecasted to reach 1.68 million by 2020.

Regardless of the biologic DMARD, the study found that patients face high initial copayments, and then fall into the coverage gap or “donut hole” by February or March. During the “donut hole” period, patients’ cost-sharing increases to 45% of drug costs (for 2015) until they reach catastrophic coverage. Patients generally reach catastrophic coverage between January and July. After that, taxpayers, insurers, and pharmaceutical companies will pick up 95% of the cost of the biologic DMARD.

A previous study of 1,100 adults with RA found that one in six reduced their medication use because of cost. “While specialty DMARDs have improved the lives of those with chronic diseases like RA, many patients face a growing and unacceptable financial burden for access to treatment,” said lead author Dr. Jinoos Yazdany of the University of California, San Francisco. “Rather than determining which drug is best for the patient, we find ourselves making treatment decisions based on whether patients can afford the drugs.”

Yazdany and his colleagues analyzed the formularies of 2,737 Medicare Part D plans in 50 states and Washington, D.C., using the January 2013 Centers for Medicare & Medicaid Services Prescription Drug Plan Formulary and Pharmacy Network Files. The researchers included DMARDS based on the 2012 American College of Rheumatology RA guidelines and on the National Committee for Quality Assurance’s DMARD quality measure. Nine biologic medications (abatacept, adalimumab, anakinra, certolizumab, etanercept, golimumab, infliximab, rituximab, and tocilizumab) and nine nonbiologic DMARDs (azathioprine, cuprimine, cyclophosphamide, cyclosporine, hydroxychloroquine, leflunomide, methotrexate, minocycline, and sulfasalazine) were analyzed.

Nationwide, although nearly all Part D plans covered at least one biologic DMARD, access was tightly controlled, with 95% of plans requiring prior authorization. Between 81% and 100% of plans required a coinsurance averaging 30% of the drug cost rather than a fixed copayment amount.

“Insurance payment reforms have been suggested by the U.S. government but are not widely implemented in the health care system,” Yazdany noted. “With the high cost of biologic DMARDS for RA, 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.”

Sources: Medical Xpress; April 21, 2015; and Arthritis & Rheumatology; April 21, 2015.

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