Cost of Specialty Heart and Cancer Drugs Under Medicare, WellCare, LAPRA, and Anthem

Specialty drugs are medications that cost more than $670 per month and are placed on the highest formulary tier. This includes expensive heart drugs such as brand-name anticoagulants and nearly all modern cancer therapies. Their cost varies dramatically depending on whether the patient is covered by Medicare Part D, a WellCare PDP, or LAPRA Anthem HMO/PPO.

1. Specialty Drug Costs Under Medicare Part D (2026 Rules)

Medicare Part D has a fixed annual out-of-pocket cap of $2,100 in 2026. Specialty drugs often cost thousands per fill, but once the patient reaches the cap, all remaining drugs for the year cost $0. Before reaching the cap, the patient pays 25 percent of the drug’s price. For a $10,000 cancer drug, the patient pays $2,500 until the cap is reached, after which the cost becomes $0 for the rest of the year.

Drug	Typical Price	Patient Cost Before Cap	Patient Cost After Cap
Eliquis (brand)	$862 per fill	$215 per fill	$0
Ibrance	$16,000 per fill	$2,100 total until cap	$0
Imbruvica	$14,000 per fill	$2,100 total until cap	$0
Revlimid	$16,000 per fill	$2,100 total until cap	$0

2. Specialty Drug Costs Under WellCare Part D

WellCare follows the same Part D rules. The patient pays 25 percent of the drug’s cost until the $2,100 cap is reached. After that, all drugs cost $0 for the remainder of the year. Dual-eligible patients pay nothing at any stage because Medi-Cal covers all copays and coinsurance.

Coverage Type	Cost for Specialty Drugs
Standard WellCare PDP	25 percent until $2,100 cap, then $0
Dual-Eligible (Medicare + Medi-Cal)	$0 for all drugs, including specialty

3. Specialty Drug Costs Under LAPRA Anthem HMO

LAPRA Anthem HMO has a very low annual out-of-pocket maximum, typically around $1,000. Specialty drugs fall under the highest tier, but once the patient reaches the out-of-pocket maximum, all drugs cost $0 for the rest of the year. This means even a $16,000 cancer drug becomes free after the cap is reached.

Drug	Typical Price	Patient Cost Under LAPRA HMO
Eliquis	$862 per fill	$10–$40 until OOP max, then $0
Ibrance	$16,000 per fill	$1,000 total until OOP max, then $0
Keytruda (Part B)	$73,000 per year	$1,000 total until OOP max, then $0

4. Specialty Drug Costs Under LAPRA Anthem PPO

The PPO plan has a higher out-of-pocket maximum, usually around $2,000. Specialty drugs may have higher coinsurance than the HMO, but once the patient reaches the out-of-pocket maximum, all drugs cost $0 for the rest of the year.

Drug	Typical Price	Patient Cost Under LAPRA PPO
Eliquis	$862 per fill	$40–$60 until OOP max, then $0
Imbruvica	$14,000 per fill	$2,000 total until OOP max, then $0
Opdivo (Part B)	$68,000 per year	$2,000 total until OOP max, then $0

5. Summary of Specialty Drug Cost Behavior

Medicare Part D and WellCare expose patients to high costs until the annual cap is reached, after which drugs cost nothing. LAPRA Anthem HMO and PPO cap all medical and drug spending at a much lower level, making even extremely expensive cancer drugs effectively free once the out-of-pocket maximum is met. Dual-eligible patients pay nothing under any Part D plan.