Out-of-Pocket Costs for Prostate Cancer Medications Substantially Vary by Part D Plan: An Online Tool Presents an Opportunity to Mitigate Financial Toxicity

Abstract

Introduction:

Patients with advanced prostate cancer are frequently prescribed enzalutamide or abiraterone, often requiring high out-of-pocket (OOP) costs. Many of these patients are insured through Medicare and have an option to select among 54 different Part D drug plans. However, less than 30% of patients report comparing costs before selecting a plan. An online Part D plan navigator is publicly available and allows patients to compare estimated OOP prescriptions costs. In this study, we examine the variability of OOP costs based on available Part D drug plans for patients with prostate cancer and demonstrate how an online tool could save patients thousands of dollars.

Methods:

We identified drug plans available for selection in 2023 using the online Medicare Part D Plan Finder. We sampled plan options for twelve different ZIP codes within the United States. A university sponsored specialty cancer pharmacy and online mail-order pharmacy were included for comparison. We identified OOP costs for enzalutamide and abiraterone based on all Part D plans available for selection.

Results:

On average, 24 Part D drug plans were available for each ZIP code. Median annual OOP costs were $11,626 for enzalutamide and $9,275 for abiraterone. The range of annual OOP costs were $9,854 to $13,061 for enzalutamide and $1,379 to $13,274 for abiraterone. Within certain ZIP codes, potential OOP cost savings were $2,512 for enzalutamide and $9,321 for abiraterone. Median difference of OOP cost between enzalutamide and abiraterone was $8,758.

Conclusion:

OOP costs vary considerably across Part D drug plans. The Medicare Part D Plan Finder is a simple and effective tool to identify affordable drug plans. Guidance on plan selection could save patients thousands of dollars and help mitigate the financial toxicity of treatment. Comprehensive cancer centers could include plan navigators as an essential component of treatment.

Introduction:

The financial consequences of cancer care in the United States are associated with psychological distress, worsening of symptoms, and can impact overall survival.^{i ii} Multiple patient advocacy groups have recommended including discussions about financial tradeoffs of treatment options as part of routine clinical practice.ⁱⁱⁱ However, estimating out-of-pocket (OOP) costs can be challenging in the United States because of variable insurance coverage, local pharmacy distributions, and complicated prescription pricing schemes.^{iv v} One recent study estimated that only 20% of physicians can accurately estimate OOP costs for patients,^vi which may explain why only one third of cancer patients report discussing costs with their physician.^vii

Medicare Part D plans provide insurance coverage for outpatient prescriptions to more than 49 million people in the United States.^viii The average Medicare beneficiary has a choice of 54 different Part D drug plans.^ix Patients insured through Medicare can select a new drug plan every year during the open enrollment period between October 15 and December 7 and the OOP cost implications for each plan are publicly available online for patients to compare. Plans differ widely with respect to cost-sharing models and coverage which results in highly variable OOP costs for patients despite identical prescriptions.^x There is currently no limit on individual OOP spending under Part D coverage. Consequently, patients with cancer can pay over $10,000 OOP for novel oral anticancer therapies, and this can vary widely depending on the selected plan.^xi Despite significant financial implications, less than 30% of patients report comparing drug plan pricing prior to selecting a plan.^xii

Prescriptions for oral anticancer medications have grown dramatically over the last decade despite their high cost.^xiii For example, oral targetted androgen inhibitors for advanced prostate cancer, such as enzalutamide or abiraterone, are becoming increasingly prescribed by urologists, for earlier stages of treatment, and for longer periods of time.^{xiv xv xvi}

Given the high costs of anticancer medications and variable insurance coverage, one opportunity to mitigate financial toxicity of treatment would be to select a Part D plan with the lowest possible OOP costs. We hypothesized that out-of-pocket requirements would vary between different Part D plans. In this study, we examine the range of OOP costs associated with Part D plans for patients prescribed enzalutamide or abiraterone and highlight an opportunity for patients to potentially reduce the financial toxicity of treatments.

Methods:

Study Sample

We identified Part D plans available for selection in 2023 using the online Medicare Part D Plan Finder.^xvii This website (www.medicare.gov/plan-compare) is publicly available and paid for by the U.S. Centers for Medicare & Medicaid Services. The online platform can identify all available Part D plans for Medicare subscribers within the United States. Only traditional Part D plans were included in this study. Medicare Advantage Plans and supplemental Medigap policies were excluded. Plans with supplemental financial assistance, such as Medicaid, Supplemental Security Income, Medicare Savings Program, and additional Social Security Benefits, were also excluded.

The Medicare Part D Plan Finder provides estimates of annual OOP costs including premiums, deductibles, co-pays, co-insurance, and accounts for catastrophic coverage clauses. The platform can identify if pharmacies are in-network, or if prescriptions are approved for specific Part D plans, and highlight OOP differences based on network status.

We included prescriptions for abiraterone and enzalutamide in this analysis. These medications were respectively approved in 2011 and 2012 to help treat men with metastatic castration-resistant prostate cancer and remain two of the more commonly prescribed oral targeted therapies for advanced prostate cancer.^xviii Prescription dosing and frequency in this study were based off standard treatment guidelines: 250mg abiraterone acetate, 120 tablets per month, and 40mg enzalutamide, 160 capsules per month. The OOP estimates in this study are based off a one-year duration of prescription.

Our study sample included twelve ZIP codes within the United States. ZIP codes were selected to include geographic variation within the United States and areas where comprehensive urologic oncology centers are located. The ZIP codes included in the study were 55902 (Rochester, MN), 44195 (Cleveland, OH), 10065 (New York City, NY), 77030 (Houston, TX), 21287 (Baltimore, MD), 90095 (Los Angeles, CA), 60611 (Chicago, IL), 48109 (Ann Arbor, MI), 37232 (Nashville, TN), 85054 (Phoenix, AZ), 19104 (Philadelphia, PA), and 02115 (Boston, MA).

Two pharmacies were included in each ZIP code: a hospital sponsored speciality pharmacy and a mail-order pharmacy. Speciality cancer medications are typically not available for prescription refills in retail pharmacies.

Statistical Analysis

OOP costs were collated for all twelve zip codes (Tables 1 & 2). All OOP costs were graphed together using a Box and Whisker plot to help visualize and compare data by median and quartiles (Figures 1 & 2). The range of OOP costs based on available plans was calculated to demonstrate potential cost savings (see Tables 1–2).

Table 1.

Out-of-Pocket Costs for Abiraterone among Available Part D Plans.

City	# Plans	Abiraterone
		Hospital Pharmacy		Mail-Order Pharmacy
		Median OOP Cost	Range in OOP Cost	Median OOP Cost	Range in OOP Cost
Rochester, MN / 55902	24	$9,448	$6,817 - $11,317	$8,819	$2,648 - $12,123
Cleveland, OH / 44195	24	$9,148	$1,442 - $11,387	$9,725	$2,695 - $12,024
New York City, NY /10065	19	$9,163	$1,594 - $12,044	$9,163	$2,786 - $12,044
Houston, TX / 77030	27	$9,260	$7,268 - $11,612	$9,278	$2,681 - $11,810
Baltimore, MD / 21287	22	$9,528	$1,443 - $11,911	$9,5275	$2,729 - $11,911
Los Angeles, CA / 90095	26	$9,370	$1,526 - $13,274	$10,250	$2,855 - $13,198
Chicago, IL / 60611	24	$10,122	$7,284 - $11,422	$8,936	$2,631 - $11,594
Ann Arbor, MI / 48109	24	$9,153	$1,379 - $11,407	$9,249	$2,658 - $11,843
Nashville, TN / 37232	27	$8,647	$1,413 - $11,577	$9,157	$2,659 - $11,635
Phoenix, AZ / 85054	28	$9,720	$1,485 - $11,716	$9,692	$1,962 - $11,730
Philadelphia, PA / 19104	26	$9,060	$1,482 - $11,525	$9,331	$2,731 - $11,966
Boston, MA / 2115	24	$9,272	$1,436 - $11,569	$9,682	$2,718 - $12,039

Table 2.

Out-of-Pocket Costs for Enzalutamide among Available Part D Plans.

City	# Plans	Enzalutamide
		Hospital Pharmacy		Mail-Order Pharmacy
		Median OOP Cost	Range in OOP Cost	Median OOP Cost	Range in OOP Cost
Rochester, MN / 55902	24	$11,760	$10,798 - $12,636	$11,448	$9,958 - $12,306
Cleveland, OH / 44195	24	$11,713	$11,158 - $12,634	$11,639	$10,362 - $12,197
New York City, NY /10065	19	$11,807	$11,246 - $12,472	$11,654	$10,497 - $12,444
Houston, TX / 77030	27	$11,662	$10,725 - $12,719	$11,565	$9,854 - $12,339
Baltimore, MD / 21287	22	$11,628	$10,012 - $12,665	$11,586	$10,347 - $12,387
Los Angeles, CA / 90095	26	$11,737	$11,263 - $12,872	$11,623	$10,576 - $12,513
Chicago, IL / 60611	24	$11,621	$10,742 - $12,635	$11,377	$9,870 - $12,290
Ann Arbor, MI / 48109	24	$11,589	$11,019 - $12,647	$11,637	$10,223 - $12,316
Nashville, TN / 37232	27	$11,589	$10,561 - $12,660	$11,546	$10,211 - $12,317
Phoenix, AZ / 85054	28	$11,782	$10,484 - $12,799	$11,445	$10,193 - $12,377
Philadelphia, PA / 19104	26	$11,640	$10,145 - $12,657	$11,522	$10,244 - $13,061
Boston, MA / 2115	24	$11,651	$11,184 - $12,659	$11,520	$10,388 - $12,376

Figure 1.

Patients on Medicare have up to 27 Traditional Part D Plans to Compare.

Figure 2.

Out-of-Pocket Costs for Abireratone among a sample of Part D Plans.

Results:

The number of traditional Medicare Part D plan options ranged from 19 (New York City, NY) to 28 (Phoenix, AZ). The median number of available Part D options for a given zip code were 24 plans.

Abiraterone prescriptions required a median of $9,275 in OOP costs among all Part D plans. OOP costs ranged from $1,379 (Ann Arbor, MI) to $13,274 (Los Angeles, CA). Within Los Angeles, CA, the difference in OOP costs for the most expensive plan compared to the least expensive plan was $10,343. Among all twelve cities, the median range of OOP costs between the most and least expensive Part D plan was $9,321. Median costs were similar between hospital specialty pharmacies and mail-order pharmacies, however, the most affordable OOP costs were more commonly associated with a mail-order pharmacy option (9 out of 12 cities). There was minimal variation between median costs among different cities.

Enzalutamide prescriptions required a median of $11,626 in OOP costs among all Part D plans. Costs ranged from $9,854 (Houston, TX) to $13,061 (Philadelphia, PA). Within Philadelphia, PA, the difference between the least costly plan and the most costly plan was $2,512. Among all twelve cities, the median range of out-of-pocket costs between the most and least expensive Part D plan was $1,839. The median costs were similar between hospital speciality pharmacies and mail-order pharmacies, however, the most affordable OOP costs were more commonly associated with the local hospital pharmacies (10 out of 12 cities). There was minimal variation between the median costs among different cities.

Comparing enzalutamide with abiraterone, the median costs were faily similar. However, the lowest OOP costs were for abiraterone in all twelve zip codes. Median OOP for the most affordable drug plan covering abiraterone was $1,484 compared to the lowest OOP median cost of $10,207 for enzalutamide.

Discussion

Our study demonstrates high OOP costs for Medicare patients requiring enzalutamide or abiraterone and that OOP costs vary by thousands of dollars depending on a patient’s choice of Part D plan. Traditionally, a medication’s transition from patent-protected to generically available reduces cost because competitors can drive prices down through market forces. This study shows that the median lowest OOP cost per plan for abiraterone, which became generically available in 2018, is $1,484, approximately $8,758 less than the median lowest OOP cost for enzalutamide. Our study demonstrates that transitioning to generic availability is not a guaranteed cost savings for patients, as some plans still require high OOP costs for abiraterone, and in some instances even higher than enzalutamide. Cost savings are only obtained for patients who select the cheapest plan. Regardless of brand or generic status, maximum cost savings for patients on Part D plans requires careful plan selection.

Our findings are based on an online estimator, but are consistent with a recent study reviewing actual patient payments.^xix That study found a range of OOP costs over the first six months of abiraterone or enzalutamide treatment including $0 up to $8,398, but did not include the role of Part D plans, which could explain much of the OOP variability based on our findings. Financial assistance programs may also drive OOP variability, as observed with some patients paying $0 OOP. However, the use of these programs were exlucded from our study. One report demonstrated that one third of first-time prescriptions for abiraterone and enzalutamide filled at an academic center specialty pharmacy were obtained with additional financial assistance, and 5% of patients never filled their prescription because of cost.^xx However, patients who received financial assistance waited more than three times as long to start therapy compared to patients who were able to fill their prescription without financial assistance, an unfortunate delay in care.

Ostensibly, the online Medicare Part D Plan Finder is a simple and free tool to help mitigate financial toxicity of cancer care in the United States. However, more resources are required from the healthcare system to improve patient education about plan navigation. One study found that only 5% of Medicare beneficiaries chose the cheapest plan available on the Medicare Plan Finder.^xxi Beneficiaries rarely switch plans, despite annual changes to costs and coverage that may result in an alternative plan being cheaper.^{xxii xxiii} Physicians are unable to accurately estimate OOP costs and are often uncomfortable discussing financial tradeoffs with patients.^{xxiv xxv} Until training and education improves, healthcare centers should include plan navigators as an integral part of the treatment team to help mitigate the financial toxicity of prescription medications. Targeted outreach by trained pharmacy advocates has been shown to improve Part D counseling and reduce OOP costs for patients.^xxvi Open enrollment season for plan selection occurs annually from October 15 to December 7. Physicians should reach out to their patient panel during these weeks, emphasize that OOP costs can vary between plans, disseminate the link to www.medicare.gov/plan-compare, and encourage their patients to compare costs before selecting a drug plan for the year.

The Medicare Plan Finder joins a growing body of interest in new technology and innovation to reduce drug costs for patients. GoodRx is a nationally available drug price comparison website that can provide price information to patients and doctors considering different pharmacy locations.^xxvii The Mark Cuban Cost Plus Drug Company (MCCPDC) offers direct-to-consumer generic prescriptions often well below the costs paid by Medicare, which get passed down to patients by means of deductible and co-insurance.^xxviii For example, 90 pills of abiraterone 250mg is currently offered for approximately $1,344 per year, which is similar to some of the most affordable OOP Part D plans found in our study. One study found potential Medicare expenditure savings up to $656 million if all Medicare beneficiaries obtained abiraterone from MCCPDC.^xxix

The Inflation Reduction Act of 2022 signed into law this year will have a transformative impact on OOP costs for patients insured by Medicare. Among many key provisions, the law will enact a $2,000 OOP cap for Part D prescriptions beginning in 2025. Our study demonstrates that patients prescribed enzalutamide would spend a minimum of $9,854 regardless of drug plan. A $2,000 cap for these patients will result in significant savings, alleviate the financial toxicity of cancer treatment, and likely improve treatment adherence. An estimated 1.5 million Medicare beneficiaries will be positively affected by the new cap on costs.^xxx This new law may obviate the need for the Online Drug Plan Finder to save thousands of dollars by comparing plans in the future, however, it will remain useful for patients looking to obtain a plan with the lowest possible OOP costs.

This study is not devoid of limitations. One, this analysis only focuses on two anticancer medications. Patients with advanced prostate cancer may be concurrently prescribed additional medications, such as antihypertensives or antidepressants, and ultimately be subjected to higher OOP costs than demonstrated in this analysis. Two, this study was performed during open enrollment in 2022, which occured from October 15 to December 7. Plan availability and OOP estimates change year-to-year. Three, we only included hospital speciality pharmacies. Although speciality cancer medications are prohibitted from being sold at common retail pharmacies, alternative speciality pharmacies do exist and might offer lower OOP costs compared to hospital pricing. Nonetheless, our findings of significant varaition in OOP costs depending on choice of Part D plan and the utility of the Medicare Part D Plan Finder in identifying the lowest cost plan remain important for patients, pharmacy teams, and physicians.

Conclusion

Patients insured by Medicare have a myriad of Part D plans available for comparison and plans can vary by thousands of dollars for patients prescribed oral targeted therapies for advanced prostate cancer. The online Part D Plan Finder is ostensibly a simple tool to compare plans and save costs. Plan navigation is essential to help mitigate financial toxicity of cancer care in the United States. Comprehensive cancer centers could include available staff and resources to help patients select the most affordable drug plans.

Figure 3.

Out-of-Pocket Costs for Enzalutamide among a sample of Part D Plans.

Table 3.

Lowest OOP and Range in OOP Costs based on Available Part D Plans Compared between Enzalutamide and Abiraterone.

City	Enzalutamide		Abiraterone
	Range in OOP Cost	Lowest OOP Cost	Range in OOP Cost	Lowest OOP Cost	Difference in Lowest OOP Cost
Rochester, MN / 55902	$1,838	$9,958	$4,500	$2,648	$7,310
Cleveland, OH / 44195	$1,476	$10,362	$9,329	$1,442	$8,920
New York City, NY /10065	$1,226	$10,497	$9,258	$1,594	$8,903
Houston, TX / 77030	$1,994	$9,854	$4,334	$2,681	$7,173
Baltimore, MD / 21287	$2,040	$10,012	$9,182	$1,443	$8,569
Los Angeles, CA / 90095	$1,609	$10,576	$10,343	$1,526	$9,050
Chicago, IL / 60611	$1,839	$9,870	$4,138	$2,631	$7,239
Ann Arbor, MI / 48109	$1,628	$10,223	$9,185	$1,379	$8,844
Nashville, TN / 37232	$2,099	$10,221	$8,976	$1,413	$8,808
Phoenix, AZ / 85054	$2,184	$10,193	$9,768	$1,485	$8,708
Philadelphia, PA / 19104	$2,512	$10,145	$9,235	$1,482	$8,663
Boston, MA / 2115	$1,475	$10,388	$9,321	$1,436	$8,952
Median	$1,839	$10,207	$9,210	$1,484	$8,758