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Medicare coverage gap may prompt some patients with diabetes to cut back on their medicines

Research Activities, November 2009

When the Medicare Part D drug benefit became available in 2006, some feared that many patients with diabetes would fall into the “doughnut hole” coverage gap that occurs after their drug costs exceed $2,250. After reaching that limit, patients must reach into their own pockets and spend $3,600 for medications before Medicare kicks in again to pay for prescription drugs. This could be a problem for patients with diabetes, who typically depend on medications to control their blood glucose levels. Based on data from two large California plans, a new study found that a lower than expected percentage of patients with diabetes in Medicare Advantage plans actually entered the coverage gap in 2006. Nevertheless, this rate was higher than that for the overall Medicare Advantage Part D population. The study also found that patients with diabetes who entered the coverage gap had lower than predicted subsequent monthly drug expenditures. While this may have been due to lower-than-expected drug costs and greater use of generic medications in managed care, it may potentially signal poorer drug adherence, the study authors suggest.

For example, some patients may have deliberately chosen to use fewer diabetes medications so that they would not have to pay for the drugs once their spending reached the $2,250 mark. Because not adhering to medication regimens is linked with poor health, the authors recommend that policymakers pay attention to the risk that the doughnut hole may pose for patients with diabetes enrolled in Medicare Part D plans. Their findings were based on analysis of 42,801 beneficiaries' costs from the Medicare Advantage Prescription Drug Plan in two large California health plans. The study was funded in part by the Agency for Healthcare Research and Quality (HS13902). See “Medicare Part D coverage gap and diabetes beneficiaries,” by Julie A. Schmittdiel, Ph.D., Susan L. Ettner, Ph.D., Vicki Fung, Ph.D., and others in the March 2009 The American Journal of Managed Care 15(3), pp. 189-193.

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Page last reviewed November 2009
Internet Citation: Medicare coverage gap may prompt some patients with diabetes to cut back on their medicines: Research Activities, November 2009. November 2009. Agency for Healthcare Research and Quality, Rockville, MD.