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 United States. This is known as the coverage gap or “doughnut hole” for enrollees of Medicare Part D. Medicare Part D is the federal program which subsidizes the cost of prescription drugs for Medicare beneficiaries.
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 doughnut 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.
Researchers at UCLA recently discovered 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.