Changes to Medicare Part D: Who Benefits?
Authors: Jessica K. DeMartino
Journal: Journal of the National Comprehensive Cancer Network (2010)

As part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Congress created a new drug benefit-Medicare Part D-that would provide drug coverage for Medicare beneficiaries.In the months that followed enactment of this law, pharmacists were busy educating patients regarding their choice of plan, as many pharmacies advertised that they could help senior citizens select the best plan for them based on their medication history.As of February 2010, 27.6 million Medicare beneficiaries, or 60% of all beneficiaries, received drug coverage under Medicare Part D. 1 Another 31% are covered under programs like TRICARE (military health insurance), Federal Employee Health Benefits Plans (FEHBP), Veterans Affairs, or employer plans, while 9% of Medicare beneficiaries have no drug coverage.Medicare Part D plans vary greatly in benefit design, covered drugs, and utilization management strategies.Although Medicare Part D has helped many senior citizens and disabled people receive needed medications, the program has also often been criticized because many enrollees are forced to pay large sums out-of-pocket when they reach the coverage gap or "doughnut hole."The 2010 coverage gap falls between $2830 and $6440, an amount easily reached by someone taking an oral anticancer agent.Once an enrollee and his or her plan have paid $2830 for medications (after the deductible is satisfied), the enrollee is responsible for the next $3610 or until total costs reach $6440, the so-called catastrophic coverage level.Coverage resumes after this upper expense limit is reached, and the Medicare Part D plan then pays 95% of the drug costs, with the enrollee responsible for 5%.Aside from cancer patients, many of the people who hit the coverage gap take expensive medications to treat diseases like rheumatoid arthritis and anemia.Medicare Part D plans vary in terms of providing assistance within the coverage gap.Approximately 80% of all plans offer no assistance in the coverage gap, while a small percentage (15%) offer some assistance for generic drugs.However, this is often a limited list of generic drugs. 2 Medicare enrollees must carefully choose which Medicare Part D plan to enroll in so that they receive as much assistance as possible at the lowest overall cost (including premiums, deductibles, coinsurance, and copayments).Despite the best efforts of many enrollees to choose the best plan (with or without pharmacist help), an estimated 3.4 million Part D enrollees (representing 14% of all enrollees and 26% of those using prescription drugs that are not eligible for the low-income subsidy) reached the coverage gap in 2007. 3Extrapolating that estimate suggests that 3.9 million Part D enrollees will reach the coverage gap in 2010.The Kaiser Family Foundation also reported that, on average, 15% of those using drugs in 8 select drug classes stopped taking medications in that class on reaching that gap.Considering today's economy, it is difficult to imagine that more enrollees are not forgoing medicine or reducing doses inappropriately.The new health care reform law, the Patient Protection and Affordable Care Act (P.L. 111-148), signed into law on March 23 by President Obama, Changes to Medicare Part D: Who Benefits?