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Pourali SP, Nshuti L, Dusetzina SB. Out-of-Pocket Costs of Specialty Medications for Psoriasis and Psoriatic Arthritis Treatment in the Medicare Population. JAMA Dermatol. 2021;157(10):1239–1241. doi:10.1001/jamadermatol.2021.3616
Psoriasis is a chronic inflammatory skin disease that affects 8 million people in the US and is associated with significant comorbidities such as cardiovascular disease and psoriatic arthritis.1 Psoriatic arthritis occurs in approximately 1 in 5 patients with psoriasis and may cause irreversible joint damage if untreated.2
Biologics are a safe and effective treatment option for patients with moderate-to-severe psoriasis and psoriatic arthritis. Along with their efficacy and favorable adverse effect profiles, biologics also reduce the risk of the comorbidities associated with psoriasis. The cost of biologics has grown over time, and switching or discontinuing biologics has been linked to higher overall health care costs among patients with psoriasis.3 High-cost specialty medications pose a considerable financial burden to Medicare beneficiaries who have no limit on their out-of-pocket spending. In addition, high out-of-pocket costs for biologics have been linked to lower rates of medication adherence in patients with rheumatoid arthritis.4 We aimed to examine out-of-pocket costs associated with specialty medications for psoriasis and psoriatic arthritis among Medicare beneficiaries.
We conducted a cross-sectional analysis of the Centers for Medicare & Medicaid Services Prescription Drug Plan Formulary Data from Q4-2020. This database captures prerebate unit prices, plan coverage, cost-sharing details, and utilization management (prior authorizations, quantity limits). We identified US Food and Drug Administration-approved specialty medications for psoriasis and psoriatic arthritis, including biologics and oral small molecule inhibitors. We calculated estimated out-of-pocket costs for nonsubsidized beneficiaries under the 2021 standard Medicare Part D benefit. We assumed 1 year of treatment and that patients used these medications as directed and did not take other medications. This study was deemed exempt by the Vanderbilt University institutional review board because all data used were deidentified and publicly available.
We analyzed 5011 plan formularies for 15 specialty medications. Coverage for these medications ranged from 10.0% to 99.8% across products and Part D plans (Table 1). Most plans (90.5% to 100%) required prior authorization when products were covered. Quantity limits ranged from 1.0% of plans for guselkumab to 75.4% for tofacitinib. Only 2.4% to 5.5% of plans offered these medications with a copay during the initial coverage phase, with most requiring a percentage-based coinsurance for patient cost-sharing. The median point-of-sale price (ie, excluding rebates/discounts) ranged from $3620.40 to $23 492.93 per fill (Table 2). Estimated annual out-of-pocket costs ranged from $4423 to $6950. For patients, estimated per-fill out-of-pocket cost ranged from $1234 to $3426 for their first fill and $181 to $1175 for fills under the catastrophic coverage phase.
Medicare beneficiaries needing specialty medications for psoriasis and psoriatic arthritis face very high out-of-pocket spending due to rising drug prices and the benefit’s reliance on coinsurance for patient cost-sharing. Psoriasis and psoriatic arthritis are chronic conditions; thus, treatment is long-term. Interruptions in treatment have been associated with worsening disease burden and associated comorbidies, such as cardiovascular disease.5 Previous studies have found that almost half (46%) of Medicare beneficiaries discontinue biologic treatment.6 Although patient assistance programs offset out-of-pocket spending, patients may be unaware of or not qualify for these programs. Among Medicare beneficiaries, being ineligible for low-income subsidies has been associated with lower adherence to biologics.6
To calculate out-of-pocket costs we assumed no other medication use. This is a limitation of the study because most beneficiaries take multiple medications, thus total spending would be higher with increasing medication use. We also included common dosing regimens and median per-fill prices for products selected. Patients with lower doses or less frequent administrations would likely face lower out-of-pocket costs. Prices would also vary depending on the Part D plan and the pharmacy in which the prescription was filled.
Specialty medications for patients with psoriasis and psoriatic arthritis offer improved quality of life and better outcomes for patients when used consistently; however, high out-of-pocket costs remain a major barrier for Medicare beneficiaries.
Accepted for Publication: July 23, 2021.
Published Online: September 15, 2021. doi:10.1001/jamadermatol.2021.3616
Corresponding Author: Stacie B. Dusetzina, PhD, Department of Health Policy, Vanderbilt University School of Medicine, 2525 W End Ave, Ste 1203, Nashville, TN 37203 (firstname.lastname@example.org).
Author Contributions: Mr Nshuti and Dr Dusetzina had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Pourali, Dusetzina.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Pourali.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Pourali, Nshuti.
Obtained funding: Dusetzina.
Conflict of Interest Disclosures: Dr Dusetzina reports grants from the Arnold Ventures, the Commonwealth Fund, and the Robert Wood Johnson Foundation for unrelated work. She also receives honoraria from West Health and the Institute for Clinical and Economic Review (advisory panel member) and was a consultant for the National Academy for State Health Policy on an unrelated project. No other conflicts are reported.
Funding/Support: This project was supported by grants from The Commonwealth Fund and the Leukemia & Lymphoma Society (Dusetzina).
Role of the Funder/Sponsor: The Commonwealth Fund and the Leukemia & Lymphoma Society had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.