Three Ways to Help Patients Navigate the Medicare Coverage Gap

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Throughout the year, many Medicare patients end up not filling their high-cost prescriptions due to the Medicare coverage gap. What can drug manufacturers do to help their Medicare patients stay adherent? 

The Medicare coverage gap, or “donut hole,” is a phase of Medicare prescription insurance coverage in which a patient is exposed to higher out-of-pocket costs for their prescriptions after a temporary limit has been reached on what the drug plan will pay. Medicare patients who hit this coverage gap often experience higher costs for their prescription medications compared to their initial phase of coverage, which leads to patients abandoning scripts and thus reduces overall adherence. However, pharmaceutical manufacturers can employ a variety of strategies to help reduce the burden of the Medicare coverage gap and build Medicare adherence. 

How the Medicare Coverage Gap Works

The coverage gap is typically reached after a patient progresses through their deductible and initial coverage phases. If a plan has a deductible phase, the patient is usually asked to pay 100% of the cost of their prescriptions before the Medicare plan begins to pay its share of the cost. In the initial phase, patients are asked to pay a copayment or coinsurance for each prescription. In 2021, once the patient and plan have paid a combined $4,130 on prescription drugs, the coverage gap phase, or donut hole, begins. During the coverage gap, patients will pay no more than 25% of the cost for a brand-name or generic drug. Once a total of $6,550 is spent out-of-pocket, the patient is out of the gap and enters the catastrophic phase of coverage. In this final phase, the patient is responsible for a small cost-share for the rest of the year.  

Although the amount patients are at risk for in the coverage gap has been lowered in recent years, higher out-of-pocket costs during this time period can lead to patients struggling to afford their medications and ultimately to non-adherence or switching to alternative prescriptions. In fact, data show that 70% of patients do not fill a script when they have to pay more than $250. The good news is that manufacturers and brands can assist patients who are experiencing coverage challenges through cost transparency tools, innovative copay assistance programs, and more tailored outreach and messaging.  

Solution 1: Cost Transparency Tools

Patients are often first exposed to the price of a medication at the pharmacy counter, where they may be surprised about the price of their medication and feel limited in what options they have. A real-time benefit check tool enables patients to learn about their cost options in real-time before they visit the pharmacy.  

For patients in the Medicare deductible or coverage gap phases, real-time benefit checks take the confusion and surprise of an increased out-of-pocket cost out of the picture. Pharmaceutical manufacturers can harness real-time benefit check tools to help tailor messaging and payment options to engaged users at the moment when they investigate the drug’s cost.  

Solution 2: Prescription Assistance Programs

While Medicare copay support offerings can be limited, there are solutions that brands can deploy to assist patients experiencing coverage and access hurdles. There are alternative solutions to a traditional copay program or a direct-to-consumer pharmacy solution, which can help to optimize the Medicare patient journey through their insurance benefits and manufacturer-sponsored assistance programs. Building out these unique solutions can help brands find success in the Medicare space and create solutions for all patients.  

Solution 3: Tailored Outreach and Messaging

Medicare patient engagement does not have to end with price transparency and assistance programs. Brands can use data generated from actual patient behavior to tailor a patient outreach experience, helping to better connect to their Medicare patients and build loyalty.  

Truveris’ patient messaging and adherence platform, truConnect, enables brands to identify Medicare patient coverage and out-of-pocket trends. The brand can then harness this data to deploy timely and targeted messaging to their Medicare patients using the truConnect platform, ultimately driving adherence and providing a better patient engagement experience.  

Brands that combine these transparency tools, copay assistance programs, and lifestyle messaging can successfully develop a Medicare patient journey that mitigates confusion and delivers a more patient-centric experience. These engaged patients will place more confidence in the brands that use these strategies and are more likely to overcome access challenges, such as the Medicare coverage gap, to stay adherent.  

Truveris is a leading digital health company focused on delivering truth and clarity in pharmacy. Truveris’ proprietary technology, coupled with deep pharmacy expertise, helps to build a more efficient market that maximizes choice, accessibility and prescription drug affordability. Our solutions provide the insight and knowledge to help people lead healthier and more productive lives.

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