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To address this gap, we conducted a nationwide examination of 2013 Part D plans’ coverage of biologic and non-biological DMARDs. Despite the projected growth in Medicare spending on biologic DMARDs in Part D, no studies have systematically examined how Part D plans nationwide cover biologic DMARDs or the financial implications of current coverage policies. With the introduction of the Part D pharmacy benefit in 2006, coverage was significantly expanded to include self-administered biologic DMARDs dispensed through a pharmacy. Biologic DMARDs were historically covered only under Medicare’s medical insurance (Part B) as physician-administered drugs. Insurance coverage for biologic DMARDs by Medicare has grown increasingly complex. Since RA affects 2.3% of older persons and over 1 in 4 Medicare beneficiaries with RA receive biologic DMARDs, Medicare spending in this area is large, exceeding a billion dollars in 2009 ( 11, 12).

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A national survey of 1,100 adults with RA found that 1 in 6 decreased medication use due to cost, potentially resulting in worse outcomes ( 10).īecause biologic DMARDs are both efficacious and expensive, understanding how to cover and pay for them is an important policy issue. However, newer biologic DMARDs can cost over $20,000 annually, and even with insurance, many patients who require them after failing first-line drugs for disease control will face a significant financial burden for treatment ( 6– 9). In 2014, disease control is possible for many patients with early and aggressive treatment using disease modifying anti-rheumatic drugs (DMARDs), now standard components of guideline-based care ( 4, 5). Prior to the late 1990s, RA was among the most debilitating chronic conditions, with one in three patients permanently disabled within five years ( 2, 3). This is particularly true for rheumatoid arthritis (RA), a condition affecting 1.3 million people in the United States ( 1). Management of many chronic conditions has improved dramatically in the last decade with the advent of novel specialty drugs, which are often both life-changing and costly.

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