Predictive AI + RWE Prevent Medicare Gaps, Driving 6:1 ROI Through Timely Physician Engagement

Challenge

A mature brand from a top 5 pharma manufacturer faced rising risks of therapy switching and non-adherence due to the Medicare “donut hole” coverage gap. With an older patient population relying heavily on Medicare, out-of-pocket costs spiked unpredictably based on individual

medication spend. Providers lacked visibility into when patients would enter the gap, making it difficult to proactively offer financial support—often leading patients to consider lower-cost generics.

Solution

To predict when patients would enter Medicare’s “donut hole” coverage gap and proactively support therapy adherence

through timely HCP engagement OptimizeRx performed the following.

AI-Driven Predictive Modeling

Developed a proprietary AI model leveraging multiple real-world datasets.
Accurately predicted point-in-time when patients were likely to exceed Medicare spending thresholds.
Identified at-risk patients just before entering the coverage gap where medication costs spike.

Targeted Provider Engagement

Delivered brand-specific financial support information to treating physicians.
Integrated messaging directly within the EHR workflow.
Ensured outreach occurred at the point of care when treatment decisions were being made.

Results

Program Duration: 6 months

Impact:

Enabled identification of previously unknown physicians treating at-risk patients, expanding outreach.
Increased engagement by delivering support only when relevant to patient needs.
Enhanced provider-patient interactions by adding meaningful, timely value.

Case Study