In this series, we have discussed the development of immunosuppressant drugs to prevent the rejection of solid organ transplants. However, another major issue is the cost and availability of these drugs, as well as the cost of the transplant itself.
Under the American healthcare system, anyone undergoing an organ transplant must have some sort of insurance coverage. The average reported cost of a solid organ transplant ranges from $260,000 for a single kidney transplant to over $1.2 million dollars for combined heart and lung transplants. These are obviously not the sort of expenses that the average family can afford without insurance, and often a significant amount of the cost must still be borne by the transplant recipient in the form of co-pays and deductibles. These costs are incurred at a time when the transplant recipient is unlikely to be employed due to their illness and recovery from surgery.
Even if the organ transplant recipient has been unable to work long enough to apply and be approved for Social Security Disability Insurance (SSDI), they must wait for two additional years after they have been approved before they become eligible for Medicare Parts A and B. If the recipient’s transplant surgery is covered by Medicare Part A, then their immunosuppressant drugs are eligible to be covered by Medicare Part B. If, however, their condition worsened to the point of necessitating organ transplant prior to their Medicare eligibility date, and the surgery was not covered under Medicare Part A, then the transplant recipient’s immunosuppressive drugs will not be eligible for coverage by Medicare Part B, although medical care related to the transplant will be covered just like any other medical expense.
There are special Medicare rules for kidney transplant recipients. Most people with kidney failure are eligible for Medicare three months after starting dialysis, regardless of their age. Until recently, even if the transplant surgery was covered under Medicare Part A, the immunosuppressive drugs would only be covered for 36 months after the surgery. In December 2020, an important piece of legislation was signed into law. Starting January 1, 2023, kidney transplant recipients under age 65 who are living with a kidney transplant and meet other criteria, will be eligible for Medicare coverage of immunosuppressive drugs for the life of the transplant.
Long term oral maintenance immunosuppression and other prescription medications can cost patients upwards of $2,500 per month depending on various factors including the number of prescription medications and insurance coverage. The average annual cost of transplant medications is reported to be between $10,000 and $14,000 per patient according to the American Society for Transplant (AST). The billed charges for all outpatient drugs prescribed from discharge from transplant surgery to 180 days post-transplant discharge is estimated between $18,200 and $30,300 for kidney transplant and heart transplant, respectively. This cost includes immunosuppressant medications and other transplant related and non-transplant related prescription medications.
Representative pricing, circa 2015, for the various immunosuppressive drugs is shown below:
| Drug (generic name) | Dosage Form | Average Dose | Estimated cost/month ($) |
| Prograf (tacrolimus) | 1 mg capsule | 4 mg BID | 1,252 |
| Tacrolimus | 1 mg capsule | 4 mg BID | 1,068 |
| Neoral (cyclosporine, modified) | 100 mg capsule 25 mg capsule | 150 mg BID | 701 |
| Cyclosporine, modified | 100 mg capsule 25 mg capsule | 150 mg BID | 493 |
| Cellcept (mycophenolate) | 250 mg capsule | 1 g BID | 1,886 |
| Mycophenolate | 250 mg capsule | 1 g BID | 950 |
| Myfortic (mycophenolic acid) | 180 mg tablet | 720 mg BID | 1,219 |
| Mycophenolic acid | 180 mg tablet | 720 mg BID | 1,094 |
| Rapamune (sirolimus) | 1 mg tablet | 2 mg daily | 1,212 |
| Sirolimus | 0.5 mg tablet | 2 mg daily | 1,038 |
| Zortress (everolimus) | 0.5 mg tablet | 1 mg BID | 1,908 |
Most of the drugs shown above are generic formulations, but they still cost close to or more than $1,000 per month. Cyclosporine and Neoral are the lowest priced drugs on the list, and that is probably because cyclosporine was created forty years ago in 1983.
As addressed in previous posts, the existing transplant medications all have their downsides due to side effects and incomplete protection from organ rejection, and yet their costs remain prohibitive. This frequently places an enormous financial burden on transplant recipients and their families.
Per the report referenced above as table source data:
“A recent descriptive survey of transplant centers captured the prevalence of immunosuppressive medication-related problems that kidney-transplant recipients experience. When asked the question what percentage of kidney transplant recipients followed at a transplant center were not taking their maintenance immunosuppressive drugs as prescribed because of difficulties associated with their ability to pay for their medications, 28% of adult programs listed 0-5% of their patients not taking their immunosuppressive drugs as prescribed, 25.3% of centers reported problems in 6-10% of patients and 32% of programs listed 11-20% of patients had difficulty paying for medications.”
It is tragic that recipients who waited so long to receive their life-saving organ transplant, and paid such an exorbitant price for the surgery, are subsequently placed at risk of losing that organ because of an inability to pay for immunosuppressive drugs. Although this gift of life can restore health to the transplant recipient, it often comes with a staggering economic burden.
With improved transplant methods, recipients’ lifespans are extended, making the ongoing cost of immunosuppressive drugs a constant long-term financial requirement. There is increasing demand for drugs with fewer major side effects that contribute to severe illness and death, but these newer agents may be even more costly than those currently in use. The perfect drug would offer better graft function, fewer rejection episodes, and still be priced at a level that would foster better adherence. Such a combination is unlikely to occur under the current system. However, the AST is working with Congress to gain funding for research into new immunosuppressive drugs while also attempting to address the lack of affordability of conventional therapy.
You can read more about the AST programs and choose to get involved at this link:
https://www.myast.org/research/need-research-support
Currently, there is a patchwork of programs in place to assist transplant recipients who have difficulty in paying for their medications. These programs vary state by state and from one transplant center to another. Most transplant recipients begin their search for assistance by contacting a transplant social worker at their individual transplant center.
Dawn Levitt, Author 