The Medicare Donut Hole: Now You're Covered, Now You're Not

This press release is an announcement submitted by SpringerLink, and was not written by Diabetes Health.

New study identifies medical conditions which put seniors at high risk of unsubsidized medical prescription expenses

Apr 2, 2010

If you're older, a woman, and suffering from either dementia or diabetes, you are the most likely to be exposed to unsubsidized medication costs in the US. This is known as the coverage gap for enrollees of Medicare Part D - the US federal program which subsidizes the cost of prescription drugs for Medicare beneficiaries. According to Dr. Susan Ettner from UCLA in the US, and her colleagues, these clinically vulnerable groups should be counseled on how to best manage costs through either drug substitution or discontinuation of specific, non-essential medications. This is important so that more essential medication is not discontinued with adverse effects on patients' health, for cost reasons only. Their findings¹ have just appeared online in the Journal of General Internal Medicine², published by Springer.

In 2006, 3.4 million seniors signed up to a Part D plan which provides voluntary drug coverage to all Medicare beneficiaries. The plan was expected to improve adherence to drug regimens and health outcomes, via improved financial access to medications. However, the standard Part D benefit includes a coverage gap (or donut hole). After a Medicare beneficiary surpasses the prescription drug coverage limit, he or she becomes financially responsible for the entire cost of prescription drugs until the expense reaches another threshold - the catastrophic coverage threshold.

Dr. Ettner and team investigated which beneficiaries were more likely to fall into the gap, and in particular which medical conditions put them at high risk of gap entry as well as the medications contributing most to pre-gap spending. The researchers looked at records from over 287,000 Medicare beneficiaries across eight states.

They found that 16 percent of enrollees entered the gap, with nearly 3 percent entering the gap very early on, i.e. within the first 180 days. Of those who entered the gap, only 7 percent exited again. Women and patients with dementia and diabetes were the most likely to enter the gap. Other conditions also predisposed beneficiaries to gap entry, including end-stage renal disease, coronary artery disease, chronic obstructive pulmonary disease, mental health conditions, and congestive heart failure.

As an example, an average 67-year-old woman with diabetes and a typical set of comorbidities - hypertension, hyperlipidemia, coronary artery disease and depression - would have a 54 percent chance of falling into the Medicare Part D coverage gap and being exposed to the full cost of her medication. If she fell into the gap, she would have an 11 percent chance of exiting again, but in the meantime, she would have incurred more than $3,600 in total out-of-pocket drug expenses.

The authors conclude: "Our findings suggest that medication cost-counseling interventions focusing on these clinically vulnerable subpopulations may be warranted. Physician-patient discussions about the expense and undesirable side effects of particular medications are one approach to managing outpatient drug therapy and controlling costs."

Read the full text article here.


1. Ettner S, Mangione CM et al (2010). Entering and exiting the Medicare Part D coverage gap: role of comorbidities and demographics. Journal of General Internal Medicine. DOI 10.1007/s11606-010-1300-6

2. The Journal of General Internal Medicine is the official journal of the Society of General Internal Medicine.

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Springer press release

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Categories: Diabetes, Diabetes, Government & Policy, Health Insurance

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Posted by Anonymous on 5 April 2010

I'm a Registered Nurse/Diabetes Educator and the reason why so little people don't exit the donut hole is because they can't afford the almost $4,000 out-of-pocket expense occurred while they are in the donut hole. They just simply stop taking their meds. When you look at the big picture, how is someone who is on a fixed income supposed to afford the FULL cost of their polypharmacy needs with skyrocketing medication prices???? Most can't. I do agree that people should be counseled on getting generic prescriptions when available which would definately help some. Being a Type 1 diabetic myself, I'm scared to death for the day I have to retire/go on social security. If I'm lucky, I will die before that time.
Thanks for listening!

Tired of the System

Posted by Jody on 16 April 2010

I am on SSDI(disability). I am 53 yrs old. I have been a type 1 brittle diabetic since I was diagnosed in 1971.

I have been on an insulin pump for the last 3 yrs. I feel like I have gotten my life back since I have started using an insulin pump. Medicare pays for a portion of my pump supplies, however they will only cover the cost for testing my BS 3x a day. Being a brittle diabetic, I must test my BS every 2-3 hrs. As a brittle type 1, my BS fluctuates and I have hypoglcemic unawareness. My BS can drop from 170 to 40 in a matter of minutes. So it is imperative that I test 8-10 times a day.

Medicare(blue cross blue shield of illinois) refuses to cover the cost of test strips. They will not cover a continuous glucose monitor until after I have purchased one. I have sent in documentation, letters of necessity, 6 mo of BS showing extremely low BS: below 40. when I pass out, my spouse administers glucagon. I would not survive if I waited for an ambulance. I see my Dr. every other month and a diabetic educator. My A1c is continuously a 6.5, however this is a false example of well controlled BS.

it is criminal that after paying into a system for 35 yrs for medical coverage I am still unable to receive adequate medical care. With the recent changes for prescription coverage 3 of my medications are no longer covered. my income is fixed at $800 a month. With mortgage payments & utilities, how will I survive?

This is a crime. You pay and pay and pay and yet you still do not receive the care necessary to survive. Yes asthere are appeals, however I have been trying to have a meeting scheuled for almost 3 yrs. It is a shame that our government runs this program or maintained that it is running to the advantage of many. In reality it is a shame as well as a disgrace.


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