Understanding Cost Burden of HIV, PrEP Under Medicare Part D

Addressing the high costs of antiretroviral therapy (ART) and preexposure prophylaxis (PrEP) are key to ending the HIV epidemic, stated researchers in a study published in JAMA Network Open.

Chien-Wen Tseng, MD, MS, MPH, department of family medicine and community health, John A Burns School of Medicine, University of Hawaii, Honolulu, HI, and colleagues conducted a nationwide cross-sectional analysis of 2019 Part D plans to determine the cost burden of ART and PrEP. They noted that Medicare covers 1 of 4 persons living with HIV and that the current Medicare Part D drug benefit imposes complicated cost-sharing between patients and stakeholders.

The 2019 Medicare formulary and pricing files for 3326 Part D plans, which contain drug benefit data—including prices and cost-sharing requirements—were analyzed.

“For 18 ART and 2 PrEP regimens, the out-of-pocket costs for patients and the cost borne by plans, manufacturers, and Medicare were projected for 1 year of treatment or prevention under a 2019 standard Medicare Part D insurance plan. Analyses assumed that patients used the ART or PrEP regimen and no other medications,” explained Dr Tseng and colleagues.

Annual costs for ART in 2019 ranged from $24 010 to $46 770) with patients expected to pay 9% to 14% of the cost ($3270-$4350), insurance plans 18% to 24% ($5340-$8450), manufacturers 6% to 11% ($2370-$2750), and Medicare 53% to 67% ($12 770-$31 270).

Patients pay 15% ($2990) of the $20 570 annual cost of PrEP with insurance plans covering 22% ($4570), manufacturers 13% ($2750), and Medicare 50% ($10 260).

“For beneficiaries with low-income subsidies that cover all patient cost-sharing, Medicare would assume 67% to 76% of ART costs and 65% of PrEP costs,” noted the researchers.

Dr Tseng and colleagues continued, “Medicare Part D mandates universal ART and PrEP coverage, but high prices (>$35 000 annually for ART and>$20 000 annually for PrEP) and the design of Part D can jeopardize affordability for patients and place most of the cost burden on taxpayers.”

Further, for patients covered by the standard Medicare Part D benefit, annual out-of-pocket costs range between $3000 and $4000 unless the patient qualifies for low-income subsides.

Under a standard Medicare Part D benefit, patients pay $3000 to $4000 out-of-pocket yearly, unless they qualify for low-income subsidies, and half to two-thirds of the cost of ART and PrEP is borne by Medicare rather than insurance plans or manufacturers.

“To end the HIV epidemic by 2030, it appears that policies must address both high drug prices and revamp Medicare Part D cost-sharing,” concluded Dr Tseng and colleagues.

 –Edan Stanley

Reference:
Tseng C, Dudley RA, Chen R, Walensky RP. Medicare Part D and Cost-Sharing for Antiretroviral Therapy and Preexposure Prophylaxis. JAMA Netw Open. 2020;3(4):e202739. doi:10.1001/jamanetworkopen.2020.2739