2011 USRDS Annual Data Report
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Figure List
Figure 6.1 Sources of prescription drug coverage in Medicare enrollees, 2008
Figure 6.2 Sources of prescription drug coverage in Medicare ESRD enrollees, by age & modality, 2008
Figure 6.3 Sources of prescription drug coverage in Medicare ESRD enrollees, by race/ethnicity & modality, 2008
Figure 6.4 General Medicare & incident ESRD patients enrolled in Medicare Part D
Figure 6.5 General Medicare & prevalent ESRD patients enrolled in Medicare Part D
Figure 6.6 Patients enrolled in Medicare Part D, by dual eligibility & low income subsidy (LIS) status, 2008
Figure 6.7 Medicare Part D enrollees with low income subsidy (LIS)
Figure 6.8 Medicare Part D enrollees with low income subsidy (LIS), by age
Figure 6.9 Medicare Part D enrollees with low income subsidy (LIS), by race
Figure 6.10 Medicare Part D benefit parameters, 20062008
Figure 6.11 Medicare Part D non-LIS enrollees with specified monthly premium
Figure 6.12 Medicare Part D non-LIS enrollees with gap coverage or no deductible, 2008
Figure 6.13 Medicare Part D LIS enrollees with specified coinsurance/copayment
Figure 6.14 Total estimated net Part D payment for enrollees
Figure 6.15 Per person per year Medicare & out-of-pocket Part D costs for enrollees, 2008
Figure 6.16 Per person per year Medicare & out-of-pocket Part D costs for enrollees, by low income subsidy (LIS) status, 2008
Figure 6.17 Per person per year Part D costs for enrolled dialysis patients, by low income subsidy (LIS) status & race, 2008
Figure 6.18 Total Medicare Part B & Part D medication costs, by modality, 2008
Figure 6.19 Total per person per year Part B & Part D medication costs, by low income subsidy (LIS) status, modality, & year
Figure 6.20 Part D non-LIS enrollees who reach each coverage phase, 2008
Figure 6.21 Cumulative percent of Part D non-LIS enrollees who reach the coverage gap, 2008
Figure 6.22 Cumulative percent of Part D non-LIS enrollees who reach catastrophic coverage after reaching the coverage gap, 2008
Figure 6.23 Top 15 drugs used by Part D-enrolled hemodialysis patients, by frequency, 2008
Figure 6.24 Top 15 drugs used by Part D-enrolled hemodialysis patients, by cost, 2008
Figure 6.25 Top 15 drugs used by Part D-enrolled transplant patients, by frequency, 2008
Figure 6.26 Top 15 drugs used by Part D-enrolled transplant patients, by cost, 2008
Table A Twelve-month probability of reaching the coverage gap in Part D non-LIS enrollees, by modality, 2008
Table B Part D-covered prescription fills per person per month in Part D non-LIS enrollees, by modality, 2008
Table C Top 25 drugs used by Part D-enrolled dialysis patients, by frequency & net cost, 2008
Table D Top 25 drugs used by Part D-enrolled transplant patients, by frequency & net cost, 2008

Chapter Six

Prescription Drug Coverage in ESRD Patients (Medicare Part D)

Sections this chapter: 

Introduction

As of September, 2008, 26 million Medicare-enrolled elderly and disabled people, as well as individuals with ESRD, were enrolled in a Medicare Part D prescription-drug plan (PDP). Before 2006, these patients obtained prescription drug coverage through various insurance plans, state Medicaid programs, or pharmaceutical-assistance programs, received samples from physicians, or paid out-of-pocket. After 2006, however, the majority obtained Part D coverage. As shown on the next page, 5859 percent of elderly CKD and general Medicare patients were enrolled in Part D in 2008, compared to 72, 61, and 53 percent of hemodialysis, peritoneal dialysis, and kidney transplant patients.

The retiree drug subsidy, designed to encourage employers to supply prescription coverage to Medicare-covered retirees that is at least as valuable as the Medicare Part D standard plan, provides employers with a tax-free rebate for 28 percent of retirees' drug costs. Other patients are enrolled in employer group health plans or government/military plans ("creditable coverage") which provide coverage that is equivalent to or better than Part D.

The proportion of patients with no known source of drug coverage is highest in the peritoneal dialysis and transplant populations. Given that many of these patients are employed, it is likely that some have sources of prescription drug coverage not tracked by Medicare.

Prior to the start of the Medicare Part D program in 2006, patients dually-enrolled in Medicare and Medicaid received prescription benefits under state Medicaid programs. The Part D program, however, offers a substantial low-income subsidy (LIS) benefit to enrollees with limited assets and income, including those who are dually-enrolled. The LIS provides full or partial waivers for many out-of-pocket cost-sharing requirements, including premiums, deductibles, and copayments, and provides full or partial coverage during the coverage gap ("donut hole"). Compared to patients in the general Medicare population, a higher proportion of dialysis, transplant, and elderly CKD patients receive LIS benefits, and thus, in general, pay proportionally lower out-of-pocket costs for their Part D prescriptions.

Part D does not cover every medication prescribed to Medicare enrollees. Several drug categories including over-the-counter medications, barbiturates, benzodiazepines, anorexia and weight loss or gain medications, prescription vitamins (except for prenatal vitamins), and cough and cold medications are excluded from the Part D program by law.

The Medicare Part D program works in concert with Medicare Part B, which covers medications administered in physician offices (e.g. erythropoiesis stimulating agents (ESAs) in CKD patients), those administered during hemodialysis (e.g. ESAs, intravenous vitamin D and iron products, IV antibiotics, and resuscitative medications), and most immunosuppressant medications required in the three-year period following a Medicare-covered kidney transplant. Medicare-covered transplant patients lose eligibility for Part B benefits after three years, but, if they become Medicare-eligible due to age or disability, they again become eligible for Part B for immunosuppressant coverage. Patients whose kidney transplant is not covered by Medicare, but who become Medicare-eligible due to age or disability, can enroll in and receive their immunosuppressant medications through Part D. Prescription drugs not covered for beneficiaries under Part B may be covered by Part D, but coverage depends on whether the drug is included on the plan formulary.

Part D benefits can be managed through a stand-alone PDP or through a Medicare Advantage (MA) plan, which provides medical as well as prescription benefits. The majority of dialysis and transplant patients are covered through PDPs (as patients may not enroll in Medicare Advantage after ESRD onset), but data in this chapter encompass both types of plans.

Figure 6.1 Sources of prescription drug coverage in Medicare enrollees, 2008 (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, 2008.)

Medicare Part D Enrollment Patterns Top

Figure 6.2 Sources of prescription drug coverage in Medicare ESRD enrollees, by age & modality, 2008 (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, 2008.)

Sources of prescription drug coverage in Medicare ESRD patients vary widely by age and modality. In each age category, for example, transplant patients are markedly less likely than those on dialysis to have the low income subsidy (LIS). Younger patients on either modality have the highest Part D enrollment, and the monotonic decrease in the percentage of patients with LIS as age increases is striking three in four dialysis patients age 2044 with Part D receive LIS assistance, in contrast to just 35 percent of patients age 75 and older.

Figure 6.3 Sources of prescription drug coverage in Medicare ESRD enrollees, by race/ethnicity & modality, 2008 (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, 2008.)

The proportion of dialysis patients enrolled in Part D varies by race and ethnicity, from 67 percent among whites to 78 and 81 percent among African Americans and Hispanics, respectively. Eighty-three percent of African Americans and Hispanics with Part D coverage have LIS, compared to 64 percent of whites, and African Americans treated with dialysis are the least likely to have no known prescription drug coverage. These general trends hold true for kidney transplant patients as well, although their Part D enrollment is less than that of dialysis patients.

Figure 6.4 General Medicare & incident ESRD patients enrolled in Medicare Part D (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1. Incident (day 90; 6.4) & prevalent ESRD patients (6.5).)
Figure 6.5 General Medicare & prevalent ESRD patients enrolled in Medicare Part D (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1. Incident (day 90; 6.4) & prevalent ESRD patients (6.5).)

The steady increase in Part D enrollment among both incident and prevalent hemodialysis and peritoneal dialysis patients parallels that seen in general Medicare patients; the lower enrollment of peritoneal dialysis patients is most likely explained by their higher employment rate. Enrollment among the small number of patients transplanted within 90 days of ESRD initiation (about 2,300 per year) remains about 30 percent.

Figure 6.6 Patients enrolled in Medicare Part D, by dual eligibility & low income subsidy (LIS) status, 2008 (see page 387 for analythical methods. Point prevalent Medicare enrollees alive on January 1, 2008.s

Patients dually-enrolled in Medicaid and Medicare qualify for LIS, and, if they do not choose a plan, are automatically enrolled in a Medicare Part D plan. Sixty-five percent of hemodialysis patients with Part D coverage are dually-eligible LIS beneficiaries, compared to 32 percent of the general Medicare population. An additional but smaller proportion of patients (612 percent) receive LIS after an application documenting low income and resources. Overall, 74 percent of hemodialysis patients with Part D coverage receive LIS benefits, compared to 64 percent of peritoneal dialysis and transplant patients, 51 percent of those with CKD, and 38 percent of general Medicare patients.

Figure 6.7 Medicare Part D enrollees with low income subsidy (LIS) (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, 2008.)
Figure 6.8 Medicare Part D enrollees with low income subsidy (LIS), by age (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, 2008.)
Figure 6.9 Medicare Part D enrollees with low income subsidy (LIS), by race (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, 2008.)

The proportion of Part D-enrolled patients with LIS declined slightly from 2006 to 2008, probably due to increasing elective enrollment among patients without dual eligiblity. The majority of younger patients (those younger than 65, primarily persons with ESRD or disabilities) enrolled in Part D have LIS. Among those age 65 and older, LIS enrollment is highest in the hemodialysis and CKD populations. By race, white Part D beneficiaries are less likely to have LIS than African Americans or those of other races. In 2008, the spread between general Medicare and hemodialysis patients with LIS was largest in white beneficiaries, at 33 percentage points.

Medicare Part D Coverage Plans Top

Figure 6.10 Medicare Part D benefit parameters, 20062008 (http://www.q1medicare.com/PartD-The-2008-Medicare-Part-D-Outlook.php)

CMS provides prescription drug plans (PDPs) with guidance on structuring a ''standard'' Part D PDP. The upper portion of this table shows the standard benefit design for PDPs in 2006, 2007 and 2008. In 2008, for example, beneficiaries shared costs with the PDP (as coinsurance or copayments) until the combined total reached $2,510 during the initial coverage period. After reaching this level, beneficiaries went into the coverage gap or "donut hole," where they paid 100 percent of costs. Since 2010, the government has been providing those reaching the coverage gap with more assistance each year. In 2008, beneficiaries who obtained a yearly out-of-pocket drug cost of $4,050 reached the catastrophic coverage phase, in which they paid only a small copayment for their drugs until the end of the year.

PDPs have the latitude to structure their plans differently from what is presented here; companies offering nonstandard plans must show that their coverage is at least actuarially equivalent to the standard plan. Many have developed plans with no deductibles or with drug copayments instead of the 25 percent coinsurance, and some plans provide generic and/or brand name drug coverage during the coverage gap.

The lower portions of the table show drug copayment, coinsurance, and deductible amounts for beneficiaries with full and non-full dual eligibility and with full or partial subsidies.

Figure 6.11 Medicare Part D non-LIS enrollees with specified monthly premium (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, excluding those in Medicare Advantage Part D plans.)
Figure 6.12 Medicare Part D non-LIS enrollees with gap coverage or no deductible, 2008 (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, excluding those in Medicare Advantage Part D plans.)
Figure 6.13 Medicare Part D LIS enrollees with specified coinsurance/copayment (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, excluding those in Medicare Advantage Part D plans.)

Patients without the low income subsidy (LIS) pay monthly premiums. Over the first three years of Medicare Part D, patient enrollment in plans with higher premiums increased. In 2008, 3034 percent of ESRD patients enrolled in plans with premiums greater than $35 per month, compared to 25 percent of general Medicare patients.

The percentage of Part D non-LIS enrollees with no deductible is similar in the general Medicare and ESRD populations, at 7276 percent. Gap ("donut hole") coverage, in contrast, is more common in the peritoneal dialysis and transplant populations, at 2324 percent compared to 19 percent among hemodialysis patients, and 12 percent for those in the general Medicare population.

Most Part D enrollees with LIS (full-benefit dual-eligible patients) do not pay monthly premiums, but non-institutionalized patients with LIS do pay drug copayments or coinsurance based on income and assets. Seventy-five percent of hemodialysis patients with LIS have low or no copayments for their Part D medications, compared to 6668 percent of peritoneal dialysis, transplant, and general Medicare patients. Only 24 percent pay 15 percent coinsurance for their medications. Even those patients with high copayments (2331 percent of patients in 2008) paid a maximum of just $2.25 per generic and $5.60 for branded medication.

Overall Costs of Part D Enrollment Top

Figure 6.14 Total estimated net Part D payment for enrollees (see page 387 for analytical methods. All patients enrolled in Part D.)

Total net Part D payment for patients with identified kidney disease (hemodialysis, peritoneal dialysis, and transplant patients, and CKD patients not on dialysis) was $5 billion in 2008 10 percent of total Part D prescription drug costs. These costs do not include costs of drugs billed to Part B, including intradialytic medications (ESAs, IV vitamin D, iron) and immunosuppressants.

Figure 6.15 Per person per year Medicare & out-of-pocket Part D costs for enrollees, 2008 (see page 387 for analytical methods. All patients enrolled in Part D.)

At $5,536 and $6,183, the per person per year (PPPY) total cost of medications covered by Medicare Part D is 2.32.5 times higher, respectively, in dialysis and transplant patients than in the general Medicare population. Proportional to total Part D costs, however, out-of-pocket costs are lower in ESRD patients, representing 8 percent of PPPY costs for hemodialysis patients and 10 percent for both peritoneal dialysis and transplant patients, compared to 19 percent in the general Medicare population.

Figure 6.16 Per person per year Medicare & out-of-pocket Part D costs for enrollees, by low income subsidy (LIS) status, 2008 (see page 387 for analytical methods. All patients enrolled in Part D.)

Across populations, total Part D medication costs are approximately twice as high in patients with LIS benefits than in those without. In the LIS population, however, out-of-pocket costs represent only 23 percent of these total expenditures, compared to 4041 percent in each of the non-LIS populations. Regardless of LIS status, total PPPY Part D costs are 1.82.4 times greater for patients with ESRD than for those in the general Medicare population.

Figure 6.17 Per person per year Part D costs for enrolled dialysis patients, by low income subsidy (LIS) status & race, 2008 (see page 387 for analytical methods. Period prevalent dialysis patients enrolled in Part D.)

Among dialysis patients with LIS benefits, Part D costs per person per year are $6,496$6,945 for whites, African Americans, and Asians, compared to $5,481 for patients of other races. There is no wide variation in costs for non-LIS populations.

Figure 6.18 Total Medicare Part B & Part D medication costs, by modality, 2008 (see page 387 for analytical methods. Period prevalent ESRD patients.)

Medicare Part D covers most medications taken by ESRD patients at home, while Medicare Part B covers those administered during dialysis (erythropoiesis stimulating agents, IV vitamin D, and so on) as well as immunosuppressive medications for patients with Medicare-covered transplants. In 2008, Medicare Part D costs for ESRD patients reached $1.54 billion, while Medicare Part B costs were $1.87 billion.

Figure 6.19 Total per person per year Part B & Part D medication costs, by low income subsidy (LIS) status, modality, & year (see page 387 for analytical methods. Period prevalent ESRD patients.)

In 2008, hemodialysis patients with LIS benefits had combined Part B and Part D medication costs of $14,536 per person per year. Regardless of LIS status, combined costs were greatest in hemodialysis patients.

Part B costs declined slightly between 2006 and 2008, most likely a result of lower ESA doses. Part D costs in dialysis patients, however, increased during this period, possibly reflecting shifting tier placement by prescription drug plans for some branded drugs. And in transplant patients, Part B and Part D costs were unstable, particularly from 2006 to 2007, which may reflect patient, pharmacy, and/or payor confusion over which program was paying for immunosuppressive medications as Medicare Part D was implemented in 2006.

Coverage Phase Analyses for Part D Enrollees Top

Figure 6.20 Part D non-LIS enrollees who reach each coverage phase, 2008 (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, excluding those in employer-sponsored & national PACE Part D plans.)
Figure 6.21 Cumulative percent of Part D non-LIS enrollees who reach the coverage gap, 2008 (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, excluding those in employer-sponsored & national PACE Part D plans.)
Figure 6.22 Cumulative percent of Part D non-LIS enrollees who reach catastrophic coverage after reaching the coverage gap, 2008 (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, excluding those in employer-sponsored & national PACE Part D plans.)

Part D enrollees who do not have the low income subsidy (LIS) may encounter three coverage phases, depending on total and out-of-pocket (OOP) costs per year. In 2008, patients with total Part D drug costs up to $2,510 fell into the initial coverage phase, while those with costs over that amount entered the coverage gap ("donut hole"), in which they were responsible for 100 percent of drug costs. Patients whose total OOP costs reached $4,050 then entered the catastrophic coverage phase, in which they paid only a fraction of overall drug costs.

In 2008, 4248 percent of CKD, hemodialysis, peritoneal dialysis, and transplant patients reached the coverage gap, and 813 percent reached catastrophic coverage, compared to 23 and 3 percent, respectively, in the general Medicare population.

On average, peritoneal dialysis patients reach the coverage gap sooner than CKD or other ESRD patients, while general Medicare patients take the longest. Twenty-four to 26 percent of ESRD patients who reach the coverage gap will subsequently attain catastophic coverage, compared to 19 percent in the CKD population, and 12.5 percent of general Medicare patients. ESRD and CKD patients thus reach catastrophic coverage much faster than do general Medicare patients.

Table 6.a Twelve-month probability of reaching the coverage gap in Part D non-LIS enrollees, by modality, 2008 (see page 387 for analytical methods. Point prevalent Medicare enrollees alive on January 1, excluding those in employer-sponsored & national PACE Part D plans.)

The twelve-month probability of non-LIS Part D enrollees reaching the coverage gap is 4548 percent across ESRD modalities, but varies by demographic characteristic. Patients age 2044, men, and African Americans are the least likely to reach the gap; by comorbidity, patients with diabetes reach it at a higher rate than do those with other diagnoses. Not surprisingly, the likelihood of reaching the gap rises with the number of prescription fills per month in the previous year. Point prevalent Medicare enrollees alive on January 1, excluding those in employer-sponsored & national PACE Part D plans.

Table 6.b Part D-covered prescription fills per person per month in Part D non-LIS enrollees, by modality, 2008 (see page 388 for analytical methods. Point prevalent Medicare enrollees alive on January 1, excluding those in employer-sponsored & national PACE Part D plans.)

Number, fill rate, and prescription cost influence whether patients stay in the initial coverage phase or progress to the coverage gap and then to catastrophic coverage. Among those who reach one of the latter two phases, transplant patients have the highest fill rate. Among those who reach the gap but do not get to catastrophic coverage, the fill rate declines once the gap is reached. This could be due either to a reduction in medication adherence or to a decision to obtain medications outside the Part D plan, and it is a pattern not seen in patients who reach catastrophic coverage. In these patients, the fill rate rises as each phase is reached. Patients with a higher number of Part D medications could be incentivized to fill prescriptions in order to reach this phase phase more quickly, as their out-of-pocket expenses then decrease dramatically.

Medicare Part D Prescription Drug Use & Costs Top

Table 6.c Top 25 drugs used by Part D-enrolled dialysis patients, by frequency & net cost, 2008

In 2008, cardiovascular and gastrointestinal medications, phosphate binders, insulin, and cinacalcet were the predominant drugs used in the dialysis population. Metoprolol, a beta blocker, continued to be the most frequently used drug, reflecting the extensive use of beta blockers for CHF and atrial fibrillation, and after myocardial infarction, PCI, and CABG. Sevelamer HCl was the predominant phosphate binder, and, at $255 million, topped the list in terms of net Part D costs, with cinacalcet coming in at $213 million. Costs for calcium acetate, insulin therapies, and lanthanum carbonate costs were each close to $50 million.

Sevelamer carbonate represented 5.3 percent of sevelamer use in 2008. Together, costs for sevelamer hydrochloride and carbonate reached $270 million about 21 percent of the $1.26 billion in Part D costs in the dialysis population. Part D claims for all dialysis patients, 2008.

Figure 6.23 Top 15 drugs used by Part D-enrolled hemodialysis patients, by frequency, 2008 (see page 388 for analytical methods. Part D claims for all hemodialysis patients, 2008.)

A Metoprolol
B Sevelamer HCl
C Insulin
D Amlodipine
E Calcium acetate
F Cinacalcet
G Lisinopril
H Clonidine
I Simvastatin
J Levothyroxine
K Clopidogrel
L Furosemide
M Carvedilol
N Omeprazole
O Atorvastatin

Figure 6.24 Top 15 drugs used by Part D-enrolled hemodialysis patients, by cost, 2008 (see page 387 for analytical methods. Part D claims for all hemodialysis patients, 2008.)

A Sevelamer HCl
B Cinacalcet
C Calcium acetate
D Insulin
E Lanthanum carbonate
F Clopidogrel
G Atorvastatin
H Esomeprazole
I Amino acids 8%
J Pantoprazole
K Sevelamer carbonate
L Lansoprazole
M Nifedipine
N Pioglitazone
O Clonidine

In 2008 hemodialysis patients, the top 15 medications (in terms of total days supply) accounted for nearly 42 percent of all Part D medications.

Sevelamer hydrochloride represented only 4.3 percent of total Part D drugs used in these patients, but accounted for 20.3 percent of their net Part D drug costs. Calcium acetate, in contrast, accounted for 3.1 percent of the medications and 4 percent of costs, demonstrating the stark contrast in costs to Medicare between use of a generic phosphate binding agent (calcium acetate) versus branded phosphate binding products (sevelamer hydrochloride or carbonate). Similarly, cinacalcet available only in branded form represented 2.9 percent of total Part D drugs used in 2008, but 16.9 percent of their costs.

Table 6.d Top 25 drugs used by Part D-enrolled transplant patients, by frequency & net cost, 2008 (see page 388 for analytical methods. Part D claims for all transplant patients, 2008.)

Among transplant patients, prednisone (a generic immunosuppressant) was the most frequently used medication in 2008, followed by metoprolol and insulin. Trimethoprim-sulfamethoxazole, used for prophylaxis against pneumocystis carinii pneumonia, was sixth on the list. Except for tacrolimus, no trade name immunosuppressant made the top 25 list in terms of frequency, not surprising given that most are covered under Medicare Part B. Valganciclovir, which is used for prophylaxis against cytomegalovirus and does not have an available generic, topped the list by cost, though not by frequency. The immunosuppressants tacrolimus, mycophenolate mofetil, sirolimus, cyclosporine, and mycophenolate sodium do appear on the list by cost, implying that their costs are relatively higher than the frequency of their use. Table 6.d; see page 388 for analytical methods.

Figure 6.25 Top 15 drugs used by Part D-enrolled transplant patients, by frequency, 2008 (see page 388 for analytical methods. Part D claims for all transplant patients, 2008.)

A Prednisone
B Metoprolol
C Insulin
D Amlodipine
E Furosemide
F Trimethoprim sulfamethoxazole/
G Atorvastatin
H Simvastatin
I Omeprazole
J Lisinopril
K Clonidine
L Nifedipine
M Levothyroxine
N Atenolol
O Pantoprazole

Figure 6.26 Top 15 drugs used by Part D-enrolled transplant patients, by cost, 2008 (see page 388 for analytical methods. Part D claims for all transplant patients, 2008.)

A Valganciclovir hydrochloride
B Tacrolimus
C Mycophenolate mofetil
D Insulin
E Cinacalcet
F Atorvastatin
G Epoetin Alfa
H Esomeprazole
I Sirolimus
J Lansoprazole
K Cyclosporine
L Pantoprazole
M Clopidogrel
N Darbepoetin alfa
O Nifedipine

Together, valganciclovir and tacrolimus represented 20 percent of all Part D drug costs for 2008 kidney transplant patients. Insulin therapies accounted for 4.7 percent of Part D medication use, but 7.1 percent of Part D costs; several new therapies continued under patent in 2008. Epoetin alfa and darbepoetin alfa, trade name products not among the most frequently used medications, were among those with the greatest cost, together accounting for 3.7 percent of Part D net costs among transplant patients.