Applying AI and RWE to Prevent Discontinuation Due to Medicare Coverage Gaps

See how OptimizeRx Evidence-Based Physician Engagement generated 46K+ incremental prescriptions by predicting when patient drug costs were about to increase.


A mature brand wanted to prevent therapy switching or non-adherence due to a known gap in Medicare coverage ‒ the “donut hole”.

  • 46K+ incremental prescriptions
  • 27% of HCPs enrolling a patient for the first time
  • 6:1 return on investment


  • Older patient population, many of which relied on Medicare for prescription coverage.
  • Coverage gap triggered at different times for different patients, based on overall medication spend.
  • Providers unaware when patients would hit the donut hole, so struggled to proactively flag financial support program.
  • Patient out-of-pocket costs increased significantly during the coverage gap, making generic alternatives more attractive.

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Applied artificial intelligence (AI) to real-world datasets to predict the exact point-in-time when patients were likely to exceed Medicare spending threshold and enter the “donut hole” coverage gap, then delivered brand-specific financial support information to their treating physician directly in the EHR.

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Predictive Algorithms

Proprietary AI model drew on multiple real-world datasets to identify patients just before they were about to enter the coverage gap where medication costs would increase.

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HCP Audience Expansion

Predictive model allowed brand to identify previously unknown physicians with patients at risk of therapy discontinuation, increasing audience size and messaging reach.

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Better Relevance and Actionability

Financial support programs introduced to HCPs only when it was relevant to their patients, increasing engagement and adding value to provider-patient interactions.

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Point-of-Care Integration

Program introduced directly in the EHR workflow, raising awareness of financial support when and where providers were making care and prescribing decisions.

Increase the impact and reach of HCP communications through AI- and RWD-driven targeting with Evidence-Based Physician Engagement.