Nationwide Coverage and Cost-Sharing for PCSK9 Inhibitors Among Medicare Part D Plans

Abstract

This study examines PCSK9i cost-sharing requirements for Medicare Part D plans nationwide, which insure 41 million beneficiaries.

Figure.. Out-of-Pocket Costs for PCSK9 Inhibitor Therapy Under a Standard 2016 Medicare Part D Drug Benefit

Under a standard 2016 Medicare Part D drug benefit, Medicare beneficiaries start each year with a $360 deductible. This is followed by the initial coverage phase, with out-of-pocket costs determined by a plan’s cost-sharing requirements for covered drugs. Once total drug costs reach $3310, beneficiaries enter the coverage gap or “donut hole,” in which they are responsible for greater cost-sharing (45% for brand-name drugs [PCSK9 inhibitors] and 58% for generic drugs [atorvastatin]). If out-of-pocket costs reach $4850, catastrophic coverage takes effect, reducing cost-sharing to 5% for the remainder of the year. We accounted for each of these coverage phases in our projections of PCSK9i cost-sharing. Standard deviations on the estimated mean monthly out-of-pocket costs range from $1 to $8.