Out-of-Pocket Costs of Specialty Medications for Psoriasis and Psoriatic Arthritis Treatment in the Medicare Population

Abstract

This cross-sectional study examines out-of-pocket costs associated with specialty medications for psoriasis and psoriatic arthritis among Medicare beneficiaries.

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.

Methods

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.

Results

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.

Table 1. Plan Coverage for Specialty Treatments of Psoriasis and Psoriatic Arthritis.

Medication	Plans, %a
	Covering medication	Requiring prior authorization	Offering medication with copay	Plans with quantity limits
Etanercept	97.5	98.8	2.9	65.2
Adalimumab	99.8	98.9	2.9	40.6
Golimumab	28.6	96.2	5.5	12.8
Ustekinumab	99.8	100	2.9	54.2
Certolizumab pegol	26.9	100	5.0	14.4
Apremilast	35.6	99.9	5.0	15.7
Secukinumab	61.8	98.4	3.3	42.1
Abatacept	43.7	97.6	4.2	20.8
Ixekizumab	13.0	90.5	2.5	49.7
Brodalumab	10.9	90.1	4.9	22.5
Tofacitinib	99.8	98.9	2.9	78.0
Guselkumab	14.9	91.8	5.1	1.0
Tildrakizumab	10.0	100	5.2	11.8
Risankizumab	70.5	98.3	2.4	75.4

^aPercentage of plans requiring prior authorization, offering medications with copay, and imposing quantity limits were calculated among plans that covered medications.

Table 2. Unit Cost of Specialty Medications for Psoriasis and Psoriatic Arthritis.

Medication	Unit, mg/mL	Point-of-sale price per fill, $, median (IQR)	Estimated patient out-of-pocket, $a
			Cost first fill	After reaching catastrophic coverage	For 1 y of treatment
Etanercept	50	5757.40 (5612.40-5953.60)	1777	289	5714
Adalimumab	40 mg/0.8 mL	5646.24 (5527.34-5834.82)	1751	283	5653
Golimumab	50 mg/0.5 mL	6006.27 (5784.87-6156.03)	1822	298	5823
Ustekinumab	90	23 413.47 (22 853.74-24 236.98)	3426	1175	6950b
Certolizumab pegol	200	4631.20 (4538.83-4932.22)	1536	240	5137
Apremilast	30 mg	3609.6 (3511.20-3760.80)	1234	181	4423
Secukinumab	150	5679.82 (5540.82-5818.50)	1744	282	5635
Abatacept	125	4650.92 (4533.88-4860.72)	1504	234	5059
Ixekizumab	80	5763.94 (5680.90-5986.31)	1781	290	5725
Brodalumab	210 mg/1.5 mL	5015.96 (4954.44-5206.88)	1599	253	5288
Tofacitinib	5 mg	4774.80 (4663.20-4935.00)	1531	239	5125
Tofacitinib XR	11 mg	4765.50 (4625.10-4932.60)	1526	238	5113
Guselkumab	100	11 511.52 (11 222.97-11 626.23)	2823	572	5686b
Tildrakizumab	100	14 112.13 (13 937.43-14 643.84)	2965	714	5107b
Risankizumab	75 mg/0.83 mL	16 248.90 (16 150.81-16 939.43)	3076	825	5550b

Abbreviation: IQR, interquartile range.

^aEstimated out-of-pocket costs were calculated for covered medications using the 2021 Medicare Part D standard benefit for brand-name drugs and the median per-fill price for each product. Patients filling non-covered drugs would pay the point-of-sale price for each fill. The 2021 standard benefit includes a $445 deductible, 25% coinsurance for drug spending in the initial coverage phase and coverage gap, and 5% coinsurance for drug spending in the catastrophic coverage phase. First fill and catastrophic coverage out-of-pocket costs are for a single fill and represent the highest (requiring patients to pay the deductible, 25% coinsurance for amounts covered in the initial phase and gap, and 5% in the catastrophic phase) and lowest (paying only 5% of the point-of-sale price) estimated out-of-pocket costs for each product. Annual out-of-pocket costs are for 12 monthly fills, unless otherwise indicated.

^bAnnual out-of-pocket spending was calculated as 4 fills per year for ustekinumab, tildrakizumab, and risankizumab and as 6 fills per year for guselkumab. For all calculations, we assume no other medication fills in order to simplify presentation. Individuals using other medications would face higher total out-of-pocket spending than that shown.

Discussion

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.