Closing the Medicare Part D Coverage Gap
Since the inception of the Medicare prescription drug plan (known as Medicare Part D), beneficiaries on numerous and/or high cost therapies have faced a period of time known as the coverage gap (or donut hole). In the coverage gap, patients pay all prescription drug costs until they hit the catastrophic dollar limit, or the calendar year ends. The donut hole existed for a variety of reasons including 1) it would lower the overall price tag of the prescription drug benefit and 2) the gap would ensure both the government and beneficiaries had "skin in the game" to ensure appropriate utilization of drugs. The coverage gap can be a challenging hurdle for many Medicare patients to meet given their retired status. In 2009, an estimated 3.4 million beneficiaries entered the coverage gap, while only 15% spent enough of their own income to hit the catastrophic limit and regain drug coverage.1
As the President and Congress turned their legislative efforts towards comprehensive healthcare reform, the closure of the coverage gap was a top priority for patient advocate groups. After significant lobbying efforts and stakeholder negotiation, the end result is that by 2020 the coverage gap will be closed for beneficiaries2.
Beginning in 2011, when beneficiaries hit the coverage gap, pharmaceutical manufacturer(s) will pay for 50% of the cost of the drug while the beneficiary is in the coverage gap, the beneficiary will pay the remaining 50% of costs. Beginning in 2011, the coverage gap cost sharing levels for the beneficiary will be reduced annually until 2020, where the level is a set 25%, thus remaining consistent with cost sharing levels of coverage before hitting the gap. Changes to the coverage gap are very positive for beneficiaries. The Centers of Medicare and Medicaid Services (CMS) have released some guidance on the logistics of how the program will actually work, but additional guidance is expected. Beyond a cost savings to beneficiaries, an additional benefit may be that patients continue on all treatment regimens through the coverage gap; improving overall health outcomes.
As a prescriber of Part D drugs, there are ways you can help your patients prepare for these changes:
Outline 2011 provision extending a 50% discount on branded drugs in the coverage gap for patients
Educate patients on changes to overall program
Provide hard copies of web-based resources for patients in your offices, as much of the internet information may not reach beneficiaries
For more information and to keep tabs on the additional changes to the Medicare prescription drug benefit, please go to:
http://www.medicare.gov/Publications/Pubs/pdf/11467.pdf
References:
1 Silva, Chris. "AARP renews campaign to close Medicare drug coverage gap" American Medical Association News website. Published June 8, 2009. Accessed March 1, 2011. Available at: http://www.ama-assn.org/amednews/2009/06/08/gvsb0608.htm
2 H.R. 3590, The Patient Protection and Affordable Care Act, Passed March 23, 2010, 111th Congress, 2nd session, available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
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