Potential impact of Medicare Part D in the end-stage renal disease population

Since 2006, end-stage renal disease (ESRD) patients enrolled in Medicare are also eligible to enroll in the voluntary prescription drug program, Medicare Part D, which is administered by private sector entities called prescription drug plans (PDPs) or Medicare Advantage Part D plans. Approximately 84% of ESRD patients should be eligible to receive Part D benefits based on Medicare coverage, but the percentage who lack adequate prescription coverage and are enrolled is unclear. Dually eligible (Medicare and Medicaid) ESRD patients were automatically enrolled in PDPs if they did not self-enroll. Many experienced problems after Part D implementation, including interruptions in prescription drug coverage, formulary issues, and difficulties when seeking appeals. Several key ESRD medications are not covered by Part D plans. Trade-name ESRD medications are often placed in higher formulary tiers requiring higher copayment. Enhanced plans covering more medications require higher premiums. ESRD patients have higher out-of-pocket expenses under Part D than general Medicare patients and are more likely to reach and go through the coverage gap and to reach catastrophic coverage. The complexities of Medicare Part D make problems inevitable; ESRD patients may be more vulnerable to these problems than the general Medicare population, but further data are needed.