Medicare Part D coverage gap and diabetes beneficiaries

Area of Science:

• Health Services Research
• Pharmaceutical Economics
• Diabetes Management

Background:

• Medicare Part D provides prescription drug coverage for beneficiaries.
• The Part D coverage gap, or 'donut hole', requires beneficiaries to pay higher out-of-pocket costs.
• Diabetes management involves significant medication expenses.

Purpose of the Study:

• To examine drug costs and entry/exit rates into the Part D coverage gap.
• Focus on beneficiaries with diabetes enrolled in Medicare Advantage managed care plans.

Main Methods:

• Cross-sectional observational study of Medicare Advantage Part D beneficiaries with diabetes.
• Data from 2 large California health plans for continuously enrolled individuals in 2006.
• Analysis of pharmacy databases to determine gap entry/exit, total drug costs, and out-of-pocket costs.

Main Results:

• 26% of beneficiaries with diabetes reached the coverage gap in 2006.
• Mean total drug costs were $2182 for the year.
• Beneficiaries entering the gap showed decreased drug expenditures later in the year, with increased out-of-pocket costs.

Conclusions:

• The diabetes patient gap entry rate was lower than some estimates but higher than the general Medicare Advantage Part D population.
• Lower drug expenditures post-gap entry may indicate managed care benefits like lower prices or increased generic use.
• Further research is needed to explore adherence and risk factors for gap entry.