Doshi Jalpa A, Li Pengxiang, Asthana Shravan, Lin John K
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
JCO Oncol Pract. 2025 Apr 25:OP2400937. doi: 10.1200/OP-24-00937.
Medicare Part D beneficiaries who do not qualify for low-income subsidies face high out-of-pocket (OOP) costs for brand-name specialty oral anticancer medications (SOAMs). We calculated how OOP costs for such SOAMs might evolve on the basis of the Inflation Reduction Act's (IRA) Part D benefit changes.
We calculated OOP costs for 10 commonly used brand-name SOAMs across various cancers under four Part D benefit scenarios: (1) 2023: before IRA implementation (pre-IRA), (2) 2024: an annual OOP maximum set at the catastrophic threshold during initial IRA implementation (mid-IRA), (3) 2025: an annual OOP maximum set at $2,000 in US dollars (USD) after final IRA implementation (post-IRA, default), and (4) 2025: $2,000 USD annual OOP maximum and voluntary enrollment in the Medicare Prescription Payment Plan (MPPP) to smooth OOP costs via monthly payments (post-IRA, opt-in MPPP).
In 2023 (pre-IRA), annual OOP costs for SOAMs ranged from $11,143 USD to $20,592 USD. In 2024 (mid-IRA) and 2025 (post-IRA), beneficiaries would only pay the new OOP maximums of $3,333 USD and $2,000 USD, respectively, regardless of SOAM prescribed or treatment duration. In 2025, the $2,000 USD OOP amount would be entirely frontloaded in January unless beneficiaries enroll in the MPPP, which could lower their OOP costs to just $167 USD for January and each calendar month thereafter, regardless of SOAM prescribed or treatment duration.
Although the annual OOP maximum enacted by the IRA will decrease OOP costs significantly for Medicare beneficiaries treated with brand-name SOAMs beginning 2025, enrollment in the MPPP is critical to avoid patients owing the entire $2,000 USD in January alone. Oncology providers have a critical role to play in ensuring beneficiaries are aware of the option to smooth their OOP costs via MPPP enrollment.
不符合低收入补贴资格的医疗保险D部分受益人在支付名牌专科口服抗癌药物（SOAM）时面临高额自付费用。我们根据《降低通胀法案》（IRA）中D部分福利变化计算了此类SOAM的自付费用可能如何演变。
我们在四种D部分福利情景下计算了10种常用名牌SOAM针对各种癌症的自付费用：（1）2023年：IRA实施前（IRA前），（2）2024年：在IRA初始实施期间（IRA中期）年度自付费用上限设定为灾难性阈值，（3）2025年：在IRA最终实施后（IRA后，默认）年度自付费用上限设定为2000美元，（4）2025年：年度自付费用上限2000美元且自愿加入医疗保险处方支付计划（MPPP）以通过每月支付来平滑自付费用（IRA后，选择加入MPPP）。
2023年（IRA前），SOAM的年度自付费用从11143美元到20592美元不等。在2024年（IRA中期）和2025年（IRA后），受益人无论开具何种SOAM或治疗时长，只需分别支付新的自付费用上限3333美元和2000美元。在2025年，除非受益人加入MPPP，2000美元的自付金额将全部在1月份预先支付，加入MPPP后，无论开具何种SOAM或治疗时长，1月份及此后每个日历月的自付费用可降至仅167美元。
尽管IRA颁布的年度自付费用上限将从2025年起显著降低使用名牌SOAM治疗的医疗保险受益人的自付费用，但加入MPPP对于避免患者仅在1月份就需支付全部2000美元至关重要。肿瘤学提供者在确保受益人了解通过加入MPPP来平滑自付费用这一选择方面起着关键作用。
