Out-of-pocket Costs

In addition to the lack of transparency on drug pricing noted by Dr Kantarjian, actual patient costs of imatinib are difficult to quantify due to the tremendous variation in commercial (private), federal, and state health insurance programs.

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Both Novartis and Sun Pharma offer out-of-pocket financial assistance for patients with commercial health insurance. For branded imatinib, the patient pays the “first $10 co-pay on a 30-day supply, and the program will pay up to $10,630 per 30-day supply up to an annual max of $30,000.”6

Those enrolled in Medicare Part D must negotiate the “donut hole,” paying “True Out-of-pocket Costs,” or TrOOP, in 4 threshold phases until costs total $4850. At that point, they move into the catastrophic phase for the rest of the year, paying the greater of 5% of total drug costs or $2.95 for each generic drug and $7.40 for each brand-name drug in 2016. For branded imatinib, 5% of the approximate $11,000 monthly drug costs is $550.

Yet even $550 a month may be unaffordable for many on Medicare. Stacie B. Dusetzina, PhD, of the University of North Carolina at Chapel Hill, Division of Pharmaceutical Outcomes and Policy, and colleagues wrote in the Journal of Clinical Oncology in December 2016 that “only 68% of Medicare beneficiaries with CML initiated TKI therapy within 6 months of diagnosis. Delayed initiation among individuals without cost-sharing subsidies suggests that out-of-pocket costs may be a barrier to timely initiation of therapy among individuals diagnosed with CML.”7

In 2015, Novartis provided an example showing that while in the donut hole, patients pay $1778 (45%) for branded imatinib vs $3752 (58%) for the generic version.8