breast cancer , the preferred first-line therapy includes two orally administered anticancer drugs : an aromatase inhibitor and an inhibitor of cyclin-dependent kinases 4 and 6 ( CDK4 / 6 ). 2 Aromatase inhibitors are low-cost hormonal therapies and have been available in generic form for several years . But the most commonly used CDK4 / 6 inhibitor , palbociclib , would cost approximately $ 3,100 out of pocket for the first fill and more than $ 10,500 for 1 year of use for a Medicare Part D beneficiary who doesn ’ t qualify for low-income subsidies ( see table ).
For a similar patient who is diagnosed with HER2-positive metastatic breast cancer , one of the preferred first-line treatment options is a combination of trastuzumab , pertuzumab , and a taxane . 3 These drugs are administered by physicians and are therefore covered under Medicare ’ s medical benefit ; for beneficiaries with supplemental coverage , the medications would be subject to an out-of-pocket spending limit or would be covered with limited or no cost sharing . The decision about whether to use an orally administered treatment or a physicianadministered treatment is dictated nearly entirely by a patient ’ s cancer type or subtype and not by a preference for a more convenient treatment option . This somewhat arbitrary distinction results in some patients paying substantially more for their cancer treatment than others , despite the same goal of extending or improving their lives .
The costs associated with orally administered anticancer treatment are similarly high for other cancer types and are high for patients with both traditional ( standalone ) and Medicare Advantage Part D plans ( see the Supplementary Appendix , available at NEJM . org ). For example , for Medicare beneficiaries not qualifying for low-income subsidies , the expected out-ofpocket cost for the first month of treatment was more than $ 3,000 for each of the 10 anticancer drugs for which Medicare Part D expenditures were highest in 2020 . Because most beneficiaries would reach
Medicare ’ s catastrophic-coverage phase — in which coinsurance is 5 % — the first time they fill their prescription , out-of-pocket costs for subsequent fills would range from $ 600 to $ 1,000 for the remainder of the year . Assuming beneficiaries filled prescriptions for these drugs every month , they would spend between $ 10,000 and $ 15,000 out of pocket for 1 year of treatment with a single drug .
These amounts should be considered in the context of older adults ’ incomes . In 2019 , the median income for older adults in the United States was $ 27,398 and varied by gender ($ 36,921 for men and $ 21,815 for women ). 4 Income limits for receiving Medicare Part D subsidies are based on the federal poverty level and are quite low : $ 18,347 for a single beneficiary and $ 24,719 for a partnered beneficiary for eligibility for a full subsidy and $ 20,385 and $ 27,465 , respectively , for eligibility for a partial subsidy in 2022 . A woman who is single and has the median income wouldn ’ t qualify for a full or partial subsidy . Should she be diagnosed with breast cancer and need palbociclib , for example , she would pay nearly half her annual income for this drug alone , not including payments for premiums and other needed medical care . Asset limits , including limits on retirement and investment savings , may further constrain access to subsidies among older adults .
Given the high list prices of orally administered anticancer drugs and the lack of an out-of-pocket spending limit under the Part D benefit , Medicare beneficiaries are at particularly high risk for not starting their prescribed medications or for stopping them early . People who do start treatment may face substantial financial challenges or may reduce their spending on other necessities , such as food and housing . 1 Beneficiaries face these difficult choices for both lowvalue and high-value anticancer drugs . Under the current benefit design , there is no difference in expected program or out-ofpocket spending based on an anticancer