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Invited Commentary
Health Policy
April 14, 2020

Cost-Sharing Under Medicare Part D: Paying Dearly to End the HIV Epidemic?

Author Affiliations
  • 1Division of Infectious Diseases, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
JAMA Netw Open. 2020;3(4):e202835. doi:10.1001/jamanetworkopen.2020.2835

In 2019, the first-ever national plan to end HIV in the US was announced. Treatment and prevention with antiretroviral drugs (ie, preexposure prophylaxis [PrEP]), both highly effective strategies, are at the core of this plan. However, access to medications to prevent or treat HIV is not ensured currently, particularly because drug costs are high and insurance coverage can sometimes leave gaps that may limit uptake and detract from adherence.

The study by Tseng and colleagues1 helps to answer a critical, practical question about such gaps: exactly how much do individuals with Medicare Part D health plan coverage pay in out-of-pocket costs for antiretroviral drugs for treatment or prevention? They analyzed 3326 Part D plans from around the US for the first quarter of 2019 to determine the annual treatment cost for 18 HIV treatment regimens and 2 HIV PrEP drugs and calculated how much each involved entity (ie, patient, plan, Medicare, or manufacturer) would pay monthly for patients with or without low-income subsidies. What they found is staggering: in the face of median annual antiretroviral prices exceeding $35 000 for treatment and $20 000 for prevention, individuals lacking low-income subsidies could have to pay as much as $3000 to $4000 out of pocket annually for HIV medications alone. Tseng et al1 also reported that cost-sharing varied throughout the year, with the highest burden to patients early on. Once the catastrophic coverage threshold was breached between February and May, Medicare bore the brunt of costs, shouldering 53% to 67% of the costs for treatment and 50% of the costs for prevention.

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    1 Comment for this article
    Chester Good, MD, MPH | University of Pittsburgh
    The co-pays are described as "shocking" and "staggering", but what about the cost of Truvada nearly tripling over the past 15 years? Additionally, Truvada is available in other countries for a fraction of the cost paid for in the US. That to me isn't shocking (sadly, we have all become numb to price increases), but it is at the root of the problem.