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OOP Costs for MS Drugs Are Substantially Higher for Non-Employer-Based Part D Plans

Summary

Employer Group Waiver Plans (EGWPs) have lower out-of-pocket (OOP) costs for multiple sclerosis (MS) drugs than beneficiaries enrolled in other types of Part D plans.

An Avalere analysis finds that the average OOP cost in 2018 for Medicare Part D beneficiaries who did not receive the low-income subsidy (LIS) and who took an MS drug was $4,115. Notably, beneficiaries enrolled in EGWPs had a substantially lower average OOP of $891 in 2018 for MS drugs, while those not in EGWPs paid $5,375.

EGWPs are a type of Part D plan that can restrict enrollment to retirees from an employer or union. While EGWPs must meet the same minimum standards for actuarial value as other Part D plans, they have additional flexibility to increase the generosity of the drug benefits offered. Often, EGWPs use this flexibility to provide plan benefits that are more like those provided to current employees than standard Part D coverage.

Prior Avalere analysis of OOP costs for patients taking 1 of 3 specialty oncology drugs found that EGWP enrollees paid roughly ⅕th the OOP of non-EGWPs taking these drugs. This analysis of MS drugs demonstrates that this OOP differential for EGWP versus non-EGWP Part D plans holds for additional therapeutic areas.

Table 1. Average Drug Costs and OOP Costs for Non-LIS Part D Beneficiaries Using an MS Agent, 2018
Per Beneficiary Average Annual
Total MS Drug Cost
Per Beneficiary Average Annual
Patient OOP Cost for MS Drugs
Non-EGWP $64,185 $5,375
EGWP $64,524 $891
All Non-LIS Beneficiaries $64,280 $4,115

Methodology

Avalere analyzed 2018 Part D prescription drug event data under a CMS research data use agreement. Avalere identified non-LIS beneficiaries taking a multiple sclerosis agent and excluded beneficiaries without a full 12 months of enrollment in the same Part D plan, residing outside the 50 states and DC, or without consistent LIS status during the year. For each cohort, Avalere analyzed drug costs and OOP costs over the course of the year.

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