Medicare Plan D--Important Information

News Story...

Medicare drug plan benefits some; others fall through cracks

By Robyn Shelton
The Orlando Sentinel

ORLANDO, Fla. - Donald Mauer used to pay $40 for a two-month supply of the potent cancer medication keeping him alive. The next time he goes to the pharmacy, Mauer will have to shell out nearly $900 for just one month's worth of the same medicine - thanks to the new Medicare prescription-drug program.

The retired teacher and his wife have been struggling for weeks to comprehend the change. "I have no idea now what we'll do - we can't afford it," said Mauer's wife of 58 years, Aileen. Mauer, 77, is an example of the millions of seniors and disabled nationwide whose drug expenses will increase this year under the Medicare program billed as a money-saver.

Politicians promoting the new plan, called Medicare Part D, promised it would help reduce the drug expenses for people who enrolled. Yet a recent poll shows six in 10 people in the new plans say they have not seen significant savings. And one study estimates as many as 7.4 million people will see their costs go up.

The landmark drug benefit is the first time Medicare has provided coverage for prescriptions outside of the hospital. All 42 million elderly or disabled Americans on Medicare are eligible to join a Part D plan offered by private insurance companies.

As of Jan. 13, about 3.6 million seniors voluntarily signed up. An additional 6.2 million automatically were switched from state coverage for their medicines to the new plan. And 4.5 million others are receiving coverage through Medicare managed-care plans. Insurance officials say most seniors stand to save hundreds or thousands of dollars this year with the coverage. On average, a senior with one chronic condition such as Alzheimer's disease, diabetes or heart disease can expect to save about $400 annually, according to a recent analysis by The Lewin Group, a health-care-policy-research company. And someone with four or more chronic medical problems should save about $1,700 annually, according to the study. Frank Battaglia, 65, expects to save at least $900 in 2006 with his Part D plan. He paid for his prescriptions entirely out of pocket when he first went on Medicare last year. He takes about five drugs regularly, including several generics that help keep his costs reasonable.

Still, the retired clothing-store owner estimates having spent more than $1,700 on medicines in 2005. Battaglia figures his total expenses this year will be about $800. He is charged a $15 co-payment for two of his medicines and gets his generic brands for free. But not everyone is as happy as Battaglia. A study by the Kaiser Family Foundation concluded that 7.4 million seniors actually will see their out-of-pocket expenses rise as a result of the new coverage. Most of the unlucky - 5 million - will see modest increases of about $250 annually. But the remaining 2.4 million will end up like the Mauers, facing considerably higher costs.

Since the program began at the first of the year, senior-advocacy groups have been fielding calls and e-mails from people complaining about their Part D coverage. In creating the drug plan, Congress prohibited Medicare from negotiating for bulk discounts with drug manufacturers - a controversial move that continues to generate criticism.

Ed Richmond, 74, said his drug costs would go up from about $13 a month before Part D to more than $300 in monthly premiums and co-payments if he goes with a Medicare drug plan.

That's because the retired heavy-equipment operator used to get some of his medicines for free through special programs offered by the drug manufacturers. However, some drug makers are discontinuing those programs for people who qualify for Medicare's drug benefit. At least two of his prescriptions no longer will be available as freebies, and Richmond said he doesn't qualify for financial assistance for Part D even though his monthly income is only about $980. The problem: He has a second vehicle - an old truck - and savings in the bank, putting him above the $11,000 asset limit for extra help from the government.

Others, such as dialysis patient Cathy Winstead, are struggling with the new co-payments for their medications that used to be covered by her state's Medicaid program but now fall under Medicare Part D.

Winstead, 68, said she lives on about $660 in Social Security benefits each month. The tiny income doesn't leave much room for new expenses, even co-payments of $3 to $5 that come with her drug benefits now.

Winstead worked at multiple jobs for many years, spending weekdays as a technician for Harris Corp. in South Florida, then showing up for weekend shifts as a security guard, waitress or short-order cook.

"I've worked my whole life so I never had to ask anybody for anything," said Winstead, who uses a wheelchair and goes to dialysis three times a week. "But I guess I'm at the point where I need help."

The Mauers get Part D insurance through Donald Mauer's benefits as a retired New York teacher. Their drug coverage used to offer a flat, $40 fee for any medications through the plan's mail-order program.

All that changed Jan. 1, when the plan started modeling its coverage after the federal government's Part D guidelines. The $40 fee was replaced with a cost-sharing structure that caused the Mauers' personal contribution to skyrocket. Their expenses will vary during the course of the year, but the first trip to the drugstore will come close to $900.

The drug, Gleevec, runs about $2,800 a month without coverage. Because of the medicine's high cost, the Mauers quickly will reach what the government calls "catastrophic coverage," and their out-of-pocket expenses will decrease at that point. But they still will end up paying much more in 2006 than ever before. Aileen Mauer estimates that she and her husband spent about $540 in total last year on his drugs, including Gleevec. The costs for his medicines alone will reach into the thousands this year. "I understand that a lot of seniors never had a drug plan before, so this (new program) is good for them," said Aileen Mauer, 76. "I don't begrudge them - that's what this should be for. But I don't understand why we have to pay so much more. Why did they have to bother with us?" A spokesman for the Centers for Medicare and Medicaid Services in Washington said the Mauers' situation is not typical for Part D beneficiaries.

"With millions of people in the program, you are going to see all sorts of different scenarios," spokesman Peter Ashkenaz said. "This [situation] is unfortunate."

60-day extension sought

WASHINGTON - Anticipating fresh problems with the Medicare prescription-drug plan, the Bush administration is telling private plans they need to provide an additional 60-day supply of medicine for emergency cases.

The move will give beneficiaries more time to find alternative treatments when their private plan won't cover a prescription. The administration's announcement came as pharmacists warned that fresh difficulties were possible as participants use up their initial 30-day emergency supply of medication.

In a review of the program's first month, Health and Human Services Secretary Mike Leavitt acknowledged Wednesday that there could be further problems in February as new people enrolled or participants switched plans. On a brighter note, however, he said premiums were likely to be a third of what was projected because of competition. "Individuals can now expect to pay on the average only $25 a month," Leavitt said.