Medicare patients face rising costs for ca drugs.(PRACTICE TRENDS)

WASHINGTON -- A new study shows that Medicare beneficiaries will be paying more out of pocket for cancer therapies in 2009, and also will have more restrictions on access than they had in the past.

The American Cancer Society's Cancer Action Network (ACS CAN) and Avalere Health, a health care consulting company, studied the changing patterns in out-of-pocket payments and presented the results at a meeting sponsored by the two organizations.

Cancer therapies are covered under Part B and Part D of the Medicare program. Beneficiaries are responsible for copayments that vary. The ACS and Avalere analysis was based on claims and formulary data for about 4,500 Medicare prescription drug plans.

The researchers found that the plans have been moving brand-name oral cancer drugs to higher formulary tiers--essentially requiring much higher copayments from patients.

Tier 1 requires no or very low copays. Cost sharing rises with each succeeding tier level, with beneficiaries being asked to make a copayment for tiers 1-3 and a percentage of the drug's cost starting on tier 4. Four-tier formularies are the most common, although some plans use as many as six tiers, said the Avalere and ACS CAN researchers.

In 2009, the drugs Gleevec (imatinib mesylate), Sutent (sunitinib malate), Tarceva (erlotinib), Thalomid (thalidomide), and Tykerb (lapatinib) will all be placed on a top formulary tier, with beneficiaries having to pay 26%-35% of the drugs' cost. These therapies cost anywhere from $2,000 to $5,000 a month, depending on the drug. Sixty-two percent to 74% of plans require prior authorization for these five therapies, and a quarter to a third limit the quantity of the drug, for instance by limiting the number of pills that can be received in a month.

This reflects a growing trend, said the analysts, noting that from 2006 to 2008, a growing number of health plans have moved Gleevec to a formulary tier requiring greater cost sharing. In 2006, only 37% had the drug on tier 4; in 2007, 73% had the drug on tier 4, and by 2008, 74% listed it as a tier 4 therapy, 8% as a tier 5, and 2% as a tier 6. In 2009, 63% of plans will list Gleevec as a tier 4 drug, 13% as a tier 5, and none as a tier 6, according to Avalere and ACS.