Entering and Exiting the Medicare Part D Coverage Gap

Role of Comorbidities and Demographics

New data will help physicians predict whether a host of medical conditions increase the risk that a patient will fall into the Medicare Part-D coverage gap. This article reports on a study that investigated associations between comorbidities and patients entering the coverage gap in 2006.

The Medicare Part-D Prescription Benefit contains a coverage gap; while in the gap beneficiaries must pay all prescription costs. Identifying medical conditions that put beneficiaries at risk for entering the coverage gap could reduce prescription costs and improve adherence to medication regimens.

This article presents the findings of a study that analyzed enrollment files and prescriptions from a Medicare Advantage Part-D prescription plan; the plan covered beneficiaries in eight U.S. states.

The study examined whether a host of medical conditions increased the likelihood that a beneficiary had entered the Medicare Part-D coverage gap in 2006. In addition, the study examined associations with patients entering the gap within the first 180 days of 2006; and, if they exited the gap before the end of 2006. The authors report their findings as the average predicted risk differences (RD) associated with each comorbidity. The authors analyzed medication costs and usage for the conditions most closely tied to entering the coverage gap.

Key Findings:

  • Dementia and diabetes created the highest risk for entering the coverage gap.
  • Diabetes nearly doubled the likelihood of gap entry.
  • Among patients who entered the coverage gap, only 6.68 percent exited the gap by the end of the year.

Identifying medical conditions that have associations with higher prescription costs could help keep Medicare beneficiaries out of the Part-D coverage gap.

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