Prescription plan still confusing

A year after the Medicare Part D prescription plan was implemented, Fort Myers seniors are still struggling to understand what it all means.

"It is exactly the same confusion as last year. There is absolutely no difference at all," said Jo Marshall, a counselor with Servicing Health Insurance Needs of Elders (SHINE). The organization works with the Area Agency on Aging and the Department of Elder Affairs.

One of the most confusing parts of the plan is what officials have called the "doughnut hole."

The first part of the plan covers 25 percent of the cost of prescription drugs until a client has reached $2,400 retail value. Additionally, a client may or may not have to pay an out of pocket deductible.

From $2,400 to $3,850, which is called the "doughnut hole," all costs must come out of the patient's own pocket. Drug companies continue to receive their checks, but patients must cover all of their medication costs. Once a patient has reached a retail drug prescription cost of $3,850, prescriptions cost 5 percent of the retail price for the rest of the year.

When Marshall starts receiving calls, most of the time it is about the "doughnut hole."

"It's not always made clear that it's talking retail value," she said. "I get several calls a week. A lot of them don't have choices. They're depleting savings accounts, moving in with children, going on Medicaid and asking for food stamps. They're selling their homes. They cry. They are so upset."

Marshall said most people hit the "doughnut hole" around October, although some spend $2,000 to $3,000 a month of prescription drugs, thus entering the gap period much earlier.

The American Pharmacist Association is airing public service announcements on radio stations in 2,000 markets, including Fort Myers, reminding seniors that they may be able to delay hitting that doughnut hole if they opt instead to use some over the counter drugs.

"We worked with pharmacists and drug manufacturers to produce the piece," said Erica Jefferson, spokeswoman for the American Pharmacist Association. "We're trying to educate seniors about the doughnut hole and how to get around it by substituting some generic and over the counter medications. They're more cost effective. We're also encouraging people to talk with their pharmacist. It's one of those issues that will not go away any time soon."

Marshall said some of her callers ask if they can skip pills or divide them in half to delay hitting the gap.

She refers those who qualify for various programs which provide financial assistance or free medications, but patients on those programs still have to spend the required $1,450 out-of-pocket expense before moving into the third part of the program.

"Medicare Part D beneficiaries who are eligible for the Medically Needy program may be able to use t h e i r f i r s t m o n t h of costs in the "doughnut hole" to meet their share of cost (since the outof pocket costs are higher) to qualify for the Medically Needy program and show enrollment in the Medicaid program," said Shelisha Durden, spokeswoman for the Agency for Health Care Administration. "They would then be eligible for the Low Income Subsidy (LIS) for the remainder of the year and would automatically be deemed eligible for LIS the following year. It should be noted that even though the dual eligible meets their Share of Cost and qualifies for Medicaid assistance, Medicaid cannot pay for their drugs since they still have part D coverage. Meeting their share of cost simply makes the recipient eligible for the Low Income Subsidy within the Medicare Part D program."

Marshall said patients will likely hit the "doughnut hole" sooner since the prescription drug companies have increased medication prices by about 6 percent.

If the program

were not

a l r e a d y c o n f u s i n g enough, some plans do not cover certain medications.

Marshall said drug prices can change every week and the tier prescriptions fall under can change once a month, but patients can only enroll in a program between Nov. 15 and Dec. 31.

There are five steps of appeal set up for patients enrolled in a plan that changes the price or drug tier, with the fifth step having the patient sue the federal government.

"I think that's wrong. I think every medication should be covered," Marshall said. "It's no wonder everyone is confused." ¦