Most patients with Alzheimer disease (AD) are not expected to reach the new Medicare Part D out-of-pocket maximum, posing a potential barrier to accessing high-cost treatments according to research presented at AMCP Nexus 2024.

Patients with AD often face cost-related barriers to accessing high-cost treatments such as lecanemab, which can exceed $6000 annually under Medicare Part B. The introduction of new subcutaneous formulations eligible for Medicare Part D coverage may help alleviate some of these financial burdens for patients. Starting in 2025, Part D plans will be mandated to cap beneficiary out-of-pocket spending at $2000, potentially increasing the likelihood of patients with AD pursuing expensive treatment options. A cross-sectional analysis was conducted on patients with prevalent AD enrolled in a Medicare Advantage Prescription Drug plan. Part D pharmacy claims were utilized to determine the percentage of patients who reached a $2000 out-of-pocket spend. Out-of-pocket costs were measured based on true out-of-pocket spend, excluding drug manufacturer discounts, as defined for 2025.

Results from a study with 114 396 patients with AD showed that 11.7% reached $2000 in Part D out-of-pocket spending by the end of the year, with a gradual increase throughout the quarters (1.8% in Q1, 3.0% in Q2, 3.7% in Q3, and 3.2% in Q4). Half of those who reached the $2000 threshold did so between May and September, while 27% reached it in Q4. Spending was mainly on drugs for other conditions, with less than 15% of the $2000 going towards AD drugs. Patients who reached $2000 had a higher comorbidity burden compared to those who did not, with the highest scores seen in patients who reached the threshold in Q1.

“Most patients with AD are not expected to reach the new Part D MOOP of $2000, and patients who do reach MOOP are expected do so mid- to late year,” said researchers. “Thus, affordability will continue to be a barrier to uptake of pipeline AD therapies that may be covered under Medicare Part D. These findings help inform the expected impact of MOOP policy changes for health plans and a better understanding of patient burden.”

Reference

Hames A, Ibrahim K, Rosen J, et al. Impact of maximum out-of-pocket spending on affordability of high-cost treatments for Alzheimer disease. Presented at: AMCP Nexus 2024; October 14-17; Las Vegas, NV.