The Out-of-Pocket Cost Burden for Specialty Drugs in Medicare Part D in 2019

Table 1: Expected Annual Costs in Medicare Part D Plans for 30 Specialty Tier Drugs, 2019
Health condition Drug name Full drug costs Out-of-pocket drug costs
Off formulary On formulary On formulary
Median annual total cost Median annual total cost Median annual out-of-pocket cost Cost above catastrophic threshold Percent of median cost above threshold
Cancer Alunbrig N/A $187,893 $11,014 $8,628 78%
Calquence N/A $171,481 $10,175 $7,868 77%
Erleada N/A $137,553 $8,586 $6,313 74%
Gleevec $145,787 N/A N/A N/A N/A
Idhifa N/A $300,858 $16,551 $14,276 86%
Imatinib mesylate N/A $91,844 $8,983 $3,883 43%
Kisqali N/A $207,084 $12,145 $9,587 79%
Nerlynx N/A $143,175 $8,842 $6,571 74%
Revlimid N/A $259,051 $14,461 $12,186 84%
Rubraca N/A $176,789 $10,386 $8,111 78%
Rydapt N/A $206,423 $11,830 $9,554 81%
Venclexta N/A $135,686 $8,712 $6,227 71%
Verzenio N/A $150,126 $9,164 $6,889 75%
Zejula N/A $202,330 $11,625 $9,350 80%
Zytiga N/A $125,351 $8,181 $5,754 70%
Hepatitis C Epclusa N/A $75,538 $5,283 $3,010 57%
Harvoni $113,400 $96,732 $6,338 $4,063 64%
Mavyret $47,522 $40,393 $3,520 $1,251 36%
Sovaldi $100,802 $82,747 $5,633 $3,368 60%
Viekira Pak $99,985 N/A N/A N/A N/A
Vosevi $89,713 $76,256 $5,306 $3,045 57%
Zepatier $26,210 $22,377 $2,622 $351 13%
Multiple sclerosis Avonex $97,799 $85,532 $6,507 $3,660 56%
Copaxone $102,456 $89,614 $6,672 $3,849 58%
Glatiramer acetate $76,375 $60,385 $7,409 $2,309 31%
Tecfidera $106,088 $92,285 $6,595 $4,238 64%
Rheumatoid arthritis Enbrel $70,171 $60,621 $5,465 $2,398 44%
Humira N/A $59,078 $5,471 $2,414 44%
Kevzara $45,514 $39,809 $4,372 $1,451 33%
Orencia $59,511 $48,838 $5,207 $1,825 35%
NOTE: Analysis reflects coverage and costs in 25 stand-alone prescription drug plans (mostly national/near-national), based on a pharmacy located in zip code 21201 (Baltimore, MD). ‘N/A’ is not applicable.
SOURCE: KFF analysis of 2019 Medicare Plan Finder data.
Table 2: Formulary Tier Placement and Utilization Management Restrictions in Medicare Part D Plans for 30 Specialty Tier Drugs, 2019
  Formulary tier placement Utilization management restrictions
Number of plans placing drug on: Off formulary Number of plans requiring:
Health Condition Drug Name Preferred brand tier Non-preferred drug tier Specialty tier Prior authorization Quantity limits Step therapy
Cancer Alunbrig 0 4 21 0 25 16 0
Calquence 0 4 21 0 25 16 0
Erleada 0 0 25 0 25 10 0
Gleevec 0 0 0 25 0 0 0
Idhifa 0 0 25 0 25 16 0
Imatinib mesylate 0 0 25 0 25 24 0
Kisqali 0 4 21 0 25 15 0
Nerlynx 0 0 25 0 25 11 0
Revlimid 0 4 21 0 25 24 0
Rubraca 0 0 25 0 25 15 0
Rydapt 0 0 25 0 25 16 0
Venclexta 0 7 18 0 25 14 0
Verzenio 0 4 21 0 25 16 0
Zejula 0 0 25 0 25 16 0
Zytiga 0 6 19 0 25 15 0
Hepatitis C Epclusa 1 0 24 0 25 15 0
Harvoni 1 0 22 2 23 13 0
Mavyret 0 0 15 10 15 6 0
Sovaldi 0 0 1 24 1 1 0
Viekira Pak 0 0 0 25 0 0 0
Vosevi 0 0 16 9 16 6 0
Zepatier 0 0 11 14 11 2 0
Multiple sclerosis Avonex 0 0 7 18 6 6 0
Copaxone 0 0 10 15 10 10 0
Glatiramer acetate 0 0 18 7 15 15 0
Tecfidera 0 0 13 12 11 8 0
Rheumatoid arthritis Enbrel 1 0 13 11 14 12 0
Humira 1 0 24 0 25 21 0
Kevzara 0 0 3 22 3 3 0
Orencia 0 0 5 20 5 0 0
NOTE: Analysis reflects coverage and costs in 25 stand-alone prescription drug plans (mostly national/near-national), based on a pharmacy located in zip code 21201 (Baltimore, MD).
SOURCE: KFF analysis of 2019 Medicare Plan Finder data.
Table 3: Expected Annual Costs in Medicare Part D Plans for 12 Specialty Tier Drugs, 2016 and 2019
Health condition Drug name Full cost
(when covered)
Median out-of-pocket cost up to catastrophic phase Median out-of-pocket cost in catastrophic phase Total median out-of-pocket cost
Cancer Gleevec* 2016 $123,158 $2,780 $5,723 $8,503
2019 n/a n/a n/a n/a
change n/a n/a n/a n/a
Revlimid 2016 $183,517 $2,780 $8,758 $11,538
2019 $259,051 $2,275 $12,186 $14,461
change $75,534 -$505 $3,428 $2,923
Zytiga 2016 $97,314 $2,780 $4,447 $7,227
2019 $125,351 $2,428 $5,754 $8,181
change $28,037 -$352 $1,307 $954
Hepatitis C Harvoni 2016 $95,824 $2,780 $4,373 $7,153
2019 $96,732 $2,275 $4,063 $6,338
change $908 -$505 -$310 -$815
Sovaldi 2016 $85,177 $2,780 $3,828 $6,608
2019 $82,747 $2,265 $3,368 $5,633
change -$2,430 -$515 -$460 -$976
Viekira Pak* 2016 $82,936 $2,786 $3,730 $6,516
2019 n/a n/a n/a n/a
change n/a n/a n/a n/a
Multiple sclerosis Avonex 2016 $64,173 $3,141 $2,838 $5,979
2019 $85,532 $2,847 $3,660 $6,507
change $21,359 -$294 $822 $528
Copaxone 2016 $73,922 $3,143 $3,305 $6,448
2019 $89,614 $2,823 $3,849 $6,672
change $15,692 -$320 $544 $224
Tecfidera 2016 $69,393 $3,167 $3,068 $6,235
2019 $92,285 $2,357 $4,238 $6,595
change $22,892 -$811 $1,170 $360
Rheumatoid arthritis Enbrel 2016 $41,564 $3,196 $1,676 $4,872
2019 $60,621 $3,068 $2,398 $5,465
change $19,057 -$128 $721 $593
Humira 2016 $42,059 $3,155 $1,709 $4,864
2019 $59,078 $3,057 $2,414 $5,471
change $17,019 -$99 $705 $606
Orencia 2016 $38,407 $2,856 $1,557 $4,413
2019 $48,838 $3,382 $1,825 $5,207

change

$10,432 $527 $268 $794
NOTE: Analysis reflects coverage in 20 stand-alone prescription drug plans in 2016 and 25 stand-alone prescription drug plans (mostly national/near-national), based on a pharmacy located in zip code 21201 (Baltimore, MD). *Viekira Pak and Gleevec are not covered by any plan in our analysis in 2019.
SOURCE: KFF analysis of 2016 and 2019 Medicare Plan Finder data.
Findings Methods