Commercial Insurance Versus Medicare: Allowed Amounts Per Member Per Month


Medicare patients paid more out-of-pocket for the most expensive drugs compared with commercially insured patients.

In 2014, oncology drugs had the highest cost per member per month (PMPM) in both commercially insured patients and patients insured by Medicare, according to Magellan RX’s Medical Pharmacy Trend Report.

The report found that Medicare patients had higher overall allowed amount PMPM costs compared with commercial insured patients.

There were 5 drug categories with a commercial allowed amount PMPM over $1.00 in 2014:

1. Oncology

The allowed PMPM cost for this drug category was the highest for this type of insurance at $8.79.

2. Oncology Support: Colony Stimulating Factors

The second most expensive was this drug category that increases the production of white blood cells to fight infections. The cost PMPM was $2.07.

3. Immune Globulin

This therapy involves treating the patient with immunoglobulin from healthy donors to give patients an increased number of antibodies. The PMPM for this treatment was $1.66.

4. BDAIDs: Crohn’s Disease/ Ulcerative Colitis

Biological drugs for autoimmune disorders (BDAIDs) for Crohn’s disease and ulcerative colitis had an average of $1.61 PMPM.

5. BDAIDs: Rheumatoid Arthritis

The biological drugs used to treat rheumatoid arthritis cost about $1.01 PMPM in 2014.

There were 6 drug categories with a Medicare allowed amount PMPM cost over $1.00 in 2014:

1. Oncology

In both types of insurance studied, oncology drugs had the highest PMPM. However, for Medicare the average cost was $20.28, which was significantly higher than the commercial insurance allowed amount.

2. Oncology Support: Colony Stimulating Factors

The cost PMPM for this drug category was $3.90. Once again, there is a gap between the 2 types of insurance.

3. Ophthalmic Injections

Intravitreal injections can be used to treat a variety of ocular conditions, such as neovascular age related macular degeneration, clinically significant macular edema, retinal vein occlusions, and more.

The cost PMPM in 2014 was $3.86, according to the report.

4. Immune Globulin

Once again, there is a fairly decent price difference between the 2 insurance coverages. For Medicare, the cost PMPM was $2.61, almost $1 more.

5. BDAIDs: Rheumatoid Arthritis

The cost PMPM was about $1.89 in 2014.

6. Oncology Support: Erythropoiesis-Stimulating Agents

This class of drugs stimulates red blood cell production and can be used to treat anemia that results from chronic kidney failure, chemotherapy, and certain HIV treatment. It is also used to reduce the amount of blood transfusions during and after surgeries.

The cost PMPM was $1.40 in 2014.

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