Medicare Part D - NY Times - Navigating the Medicare Drug Maze

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Tuesday, April 25, 2006

PERSONAL HEALTH
Forge Your Way Through the Medicare Drug Maze

By JANE E. BRODY

Some 12 million Americans eligible for Medicare's new drug insurance program have yet to enroll, and the deadline for doing so without incurring a penalty -- May 15 -- is less than three weeks away.

Although the administration says that 30 million people have prescription coverage, only 8 million voluntarily enrolled in a Medicare plan. Most of the rest already had drug insurance or were automatically rolled over into a Medicare plan.

For many reasons, people are hesitating to take advantage of this supposed benefit. The main problem has been the mandated middlemen among prescriber, patient and pharmacy.

To take advantage of the program, patients have to choose a private insurer. In every region, dozens of insurance companies offer more plans than most people seem able to sort through. You cannot, with the new Medicare Part D drug plan in tow, go to your local drugstore, flash your Medicare card and pick up your prescription.

But you can go -- and I suggest you do -- to the Medicare Web site and click on Medicare Prescription Drug Plan Finder to start. If you are not computer savvy, ask someone who is to run through the links to determine what's available in your area that will supply the drugs you use and what the programs will cost. Each plan has a monthly premium with co-payments that vary with the drug. The plans also differ in the drugs they cover.

Assembling the Information

Wending through the Web site is not challenging for someone familiar with computers. Before starting, you need a list of all the prescription drugs you take, dosages and frequency. To estimate the expected benefits from joining a plan, you have to know just how much you pay for those drugs and how much they would cost if you bought them from Canada or an organization like AARP. If the difference is not great and you can handle the payments, you may decide that it is not worth using a Medicare drug plan.

For those who have to take eight or more prescription drugs a day, chances are that a Medicare plan will turn out to be significantly money- saving -- though not necessarily sanity-saving. People who reguarly take just a few prescription drugs are likely to have the hardest time deciding what to do. They may be healthy now, but what if later in the year they develop problems that require the continued use of very costly drugs?

''People who prefer to feel more secure knowing there's a plan in place to cover a future health problem would be wise to choose a low-premium plan in case something happens down the line,'' said Deane Beebe of the Medicare Rights Center, an advocacy organization in New York.

Others may be willing to risk needing a plan later and are not bothered by having to pay a penalty for signing up after the May 15 deadline. They should know, however, that after that date sign-ups for current Medicare recipients will be allowed just once a year, from Nov. 15 to Dec. 31 each year. Future Medicare enrollees will have a seven-month window to make their decisions.

To encourage more Medicare recipients to enroll in a drug plan now, a penalty was introduced for waiting past May 15. It amounts to 1 percent of the premium for each month beyond the initial sign-up period. If premiums increase, so will the penalties for waiting.

The introduction of commercial middlemen into the drug program has caused mass confusion among potential enrollees and is the source of loopholes and glitches that many participants have already encountered. Though plans are not allowed to increase premiums this year, they can -- and probably will -- increase in future years. Also, plans can change the drugs that they cover and the co-payments for each drug at any time. They can also drop coverage of some drugs entirely, but you can change plans just in the year-end enrollment periods. If a drug is dropped, the plan has to give patients 60 days' notice or a 60-day supply of the drug.

Let's say you require an expensive drug to treat multiple sclerosis and you choose a plan that now covers it, albeit with a large co-payment. If the plan decides in August to end coverage of that drug, you may be stuck paying the full amount for the rest of the year, when with luck you can find another plan that still covers it.

There is another reason that the plan you choose today may not work for you tomorrow. During the year, you could develop an illness that requires a drug that your plan does not cover. You and your doctor can file an appeal, but the insurer is not obligated to respond favorably.

Overcoming the Hurdles

Insurers rank drugs in ways that try to discourage people from choosing more costly options, even when their doctors believe the more expensive drugs are what patients need. Some brand-name drugs will require prior authorization from the insurer, or quantity limits may be imposed. In other cases, insurers will insist that patients first try a cheaper drug.

When drugs are on an insurer's restricted list, patients' doctors may have to write letters, send their patients' medical history and, perhaps, even supporting journal articles to the insurer to appeal for coverage. When such an appeal is denied, there is supposed to be an independent review. But the Medicare Rights Center said it was still trying to help patients obtain coverage for needed drugs that were rejected in January.

Another problem can arise when patients reach what is called the ''doughnut hole'' created by Congress. This is the point in the year that a patient spends a total of $2,250 on drugs, a sum that includes out-of-pocket payments and what the plan has paid. At that point, patients have to pay 100 percent of drug costs until they have personally spent $3,600 altogether, not including premiums, drugs not covered in the plan or prescriptions filled in pharmacies not in the patient's network (for example, when patients are on a trip).

After that point, catastrophic coverage kicks in. The patient pays 5 percent of the cost of a drug (or $5 for a brand-name drug or $2 for a generic, whichever is greater).

Before signing up with a company, consumers should consider calling its customer representative to learn how responsive they are and whether drug coverage has already been changed. Provide your list of drugs and ask about the co-payments for each and the restrictions on coverage. Also, ask friends in the plan about their experiences.

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