"Seniors are open to mail order, but they either don't know it exists or do not have access to the service," he says, "but
when they do, there is a 95% satisfaction rate. Pharmacies and doctors certainly won't drive the use of mail service." PCMA examined the effect of mail service and generic use on delaying entry into the coverage gap by creating five profiles
of patients using both brand and generic drugs to treat five primary chronic diseases and by looking at four national prescription
drug plans (PDPs). The study found that beneficiaries could have saved as much as 38%, or more than $1,200 in out-of-pocket
costs in 2006. Specifically for high blood pressure and diabetes, beneficiaries could delay entrance into the gap by 61 and
157 days, saving 36% and 57%, respectively. "Congress designed the Part D benefit with a gap to keep costs at a reasonable level with lower premiums so people could afford
it," Merritt says. "It makes sense to offer both options—coverage in the gap and no coverage. In addition, beneficiaries have
access to drug discounts in the donut hole." Families USA, a healthcare consumer advocacy group, has a different perspective on whether covering generics in the donut
hole is really "meaningful" and that drugs that seniors actually use are covered. On a list of 25 most commonly used drugs
by seniors, Families USA says that only seven are available in generic form. In addition, its report, "Coverage Through the
Donut Hole Grows Scarcer in 2007," points out that some premiums will increase as much as 185% to accommodate coverage in
the gap. Iowa, Minnesota. Montana, Nebraska, North and South Dakota and Wyoming represent the highest jumps in premiums. The
study also estimates that the number of beneficiaries without access to a PDP with meaningful coverage in the gap rose from
375,000 in 2006 to 6.3 million in 2007. Merritt believes that 2008 will bring more efficiencies with lower premiums, broader formularies and a full year of data to
help plans target how to save more money for their members. As for brand-name drugs in the coverage gap, Merritt says that
eventually might be an option, but for now, plans are doing what they can to offer inexpensive alternatives. Medco Health Solutions, like most PBMs, is not providing any coverage in the gap, but does offer low copayments for generics
and flat copayments for preferred brands. "We studied how seniors chose benefits in 2006, and realized they made choices based
on premiums," says Medco's Mary Daschner, senior vice president, senior solutions. More plans are offering gap coverage now than in 2006, but still only 27% of PDPs are doing so, according to the Kaiser Family
Foundation (KFF). Most plan sponsors that offer gap coverage are only going as far as covering generics, a benefit that doesn't
push the premium too far out of sight. Mari Edlin is a frequent contributor to MANAGED HEALTHCARE EXECUTIVE. She is based
in Sonoma, calif.
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