Silver Spring resident Joseph Hock, 69, recently dropped into his local senior center for a primer on Medicare's new prescription drug benefit. Like many other Montgomery County residents, Hock is trying to figure out which of the 67 drug plans available to him best suits his needs.
"God, it is so much. It's complicated," said Hock after the presentation. "This is a very confusing process." Until this month, the retired engineer has depended on his wife's employer-provided health care benefits to cover his drug bill, which he estimated at $4,500 a year. But that coverage will end shortly, when his wife retires.
Starting today, some 42 million elderly and disabled Americans eligible for Medicare can sign up for Part D, Medicare's voluntary prescription drug benefit. On Jan. 1, 2006, the program will begin delivering discounted drug prices, substantial coverage for routine medication expenses and nearly complete insurance against drug costs that exceed $3,600 in any year. Beneficiaries who enroll will save an average of $1,200 on their drug purchases in 2006, according to federal Medicare officials.
"It's definitely worth taking a close look" at the new benefit, said Medicare's top administrator, Mark McClellan. "It's an opportunity to save thousands of dollars on your drug costs."
But understanding the program's many nuances and choosing a plan wisely will, by all accounts, demand patience and persistence.
"They are overwhelmed," said Howard Houghton, Fairfax County's coordinator of the Virginia Insurance and Counseling Assistance Program, who has been working overtime advising some of the county's 100,000 beneficiaries on Medicare's new drug plan. "They are a bit angry about why this is so complicated."
Everyone enrolled in or eligible for Medicare can enroll in Part D, no matter how high or low their income. But no one is obligated to join the program; in fact, the millions who already have better drug coverage and lower premiums -- typically through retiree benefits or Medicare managed care plans -- are being advised to stay out of Part D.
The government is urging all others -- the majority of the Medicare population -- to consider one of the many Part D plans offered by private insurers. People who want to keep their traditional Medicare coverage -- which pays for many hospitalization and doctor expenses -- can add a stand-alone prescription drug plan (PDP). Those prepared to join a managed care program can join a Medicare Advantage Prescription Drug (MA-PD) health plan -- an HMO-type option that covers most hospital, doctor and drug expenses but restricts the choice of health care providers .
In the Washington area, Medicare beneficiaries have dozens of ways to obtain drug coverage, each with a different premium, deductible and co-payment scheme. Moreover, plans differ in which drugs they'll pay for, what those drugs will cost and which pharmacies a member must use.
"No two plans are alike," concluded Kathleen Partoyan, 69, of Falls Church, after looking at the Medicare & You handbook that the government published last month. A retired benefits administrator, Partoyan said she was overwhelmed by the 54 options she found. "The premiums are all over the place."
The typical beneficiary nationally will pay $32.20 a month for Part D coverage, according to Medicare officials. In the District and Maryland, PDP premiums range from $6.44 to $68.98; the average is $33.63. In Virginia, premiums range from $8.81 to $68.61, with an average of $34.19.
Meanwhile, some of the managed care options come with zero premiums. For both PDP and MA-PD plans, the federal government pays the private insurers an average of $94.08 per month for every person who enrolls for drug coverage.
Experts say that plans with the lowest premiums are usually the ones most appropriate for people with low or no drug costs. But experts warn not to shop on premium alone.
"Very often, the plan with the lowest premium is not the one that will cost you the least at the end of the year," said John Gorman, a former Medicare official whose company, the Gorman Health Group, advises insurers on Medicare plans.
Aside from beneficiaries with drug coverage as good as or better than Part D, "it is extremely important to enroll in order to have coverage and to avoid paying a penalty" for late enrolment, said Jean Roesser, secretary of Maryland's Department of Aging. Even if people find the number of options daunting, "they are going to have to do some work. Be patient and plan."
The ABCs of Part D
Beneficiaries who fail to sign up for the drug benefit by May 15, 2006, risk paying a permanent surcharge on their premium after that date: Joining six months late would increase a monthly premium by 6 percent, while delaying for 21/2 years would jack up premiums by 30 percent.
A major exception to the premium penalty involves the roughly one-third of the nation's seniors who have substantial drug coverage through a former employer, union or the military. Sponsors of this kind of coverage were supposed to have sent beneficiaries letters by today whether their coverage is "creditable" -- i.e., as good as or better than Part D's standard benefits. If it is, such individuals will generally not face penalties if they enroll in Part D later.
Experts advise those with creditable coverage to stick with it and forgo enrolling in Part D, at least for now. But "save that letter," warns Linda Hickman, a Medicare educator with Montgomery County's Department of Health and Human Services, in case you decide later to enroll in Part D and need evidence of creditable coverage.
Virtually all other beneficiaries should sign up for Part D, many experts say. A Kaiser Family Foundation report said that about a quarter of those who sign up for Part D -- mainly those with low drug costs -- will pay more for drugs and their premiums than they spend today on drugs alone. Still, federal officials and some consumer advocates reason, Part D protects such people against unpredictable drug costs that could be enormous.
Medicare and AARP officials say that the new drug benefit is a great deal for lower-income beneficiaries who qualify for financial assistance to cover the program's out-of-pocket costs. A single senior with income under $14,355 a year and a couple making less than $19,245 would pay little to almost nothing for their drugs under Part D.
Most beneficiaries, however, will pay for their drug benefit. The standard plan contains a $250 deductible. Seniors pay 25 percent of the next $2,000 in covered costs. Beneficiaries then enter the "doughnut hole" -- a gap in coverage where they pay 100 percent of their drug costs. Once a person's drug costs reach $5,100, catastrophic coverage begins, with the beneficiary paying only 5 percent of eligible costs for the remainder of the year.
But few plans actually mirror this standard benefit. Instead, insurers are offering a wide array of plan designs.
In the District, Virginia and Maryland, for example, six PDP options offer some coverage in the doughnut hole.
Picking a Plan
Choosing a particular plan is tougher than deciding whether to enroll in Part D at all. Premiums, deductibles, coinsurance and co-payments vary with each offering, as do the medications included on a plan's list of covered drugs, or formulary.
"You may find a plan that doesn't cover all your drugs," said Hickman. "It's going to come down to, 'Is my medication covered, and is my pharmacy covered?' "
Plans with low premiums often have smaller formularies than plans with higher monthly payments. For example, Coventry AdvantraRx Value plan, with a $21 premium, covers 74 of the 100 most commonly prescribed drugs to seniors. But Coventry's two other area offerings, with premiums ranging between $31 and $45, cover 98 of the top 100 drugs. Cigna HealthCare's three PDPs cover 99 of the 100; their premiums range from $34 to $51 a month.
To help narrow your options, advised Robert Hayes of the Medicare Rights Center, an advocacy group based in New York, figure out which plans cover most of your drugs and allow you to use a pharmacy or mail-order service that is convenient for you.
To get started, beneficiaries can call 1-800-MEDICARE or check out www.medicare.gov. The telephone and online assistance can help people narrow down their choices, based on the drugs they use, the premiums they're prepared to pay, etc. But consumer advocates say many beneficiaries will need to call their Area Agency on Aging and specific insurers to get more details.
"The real key" is to consider a plan's "formulary and where the drugs you take fall on the formulary," said Gorman. Many plans have three- and four-tier formularies, making patients pay a larger share of the cost for certain expensive drugs.
For example, the AARP MedicareRx Plan requires policyholders to pay $5 for generic drugs, $28 for "preferred" brand-name drugs such as Lipitor and Fosamax and $55 for "non-preferred" brands such as Celebrex and Lotrel. The AARP plan also has a tier for "specialty" drugs, which require patients to pay 25 percent of the prescription's cost. This tier would include such drugs as Procrit and Baraclude.
Part D plans use other techniques -- such as prior authorization, step therapy and quantity limits -- to restrict access to drugs, especially the most expensive ones. "Their incentive is to reduce costs as much as they can," said Thomas Clark, director of policy and advocacy with the American Society of Consultant Pharmacists. "Some plans apply these restrictions on about half the drugs, some only on a few."
Another complication for people trying to figure costs: Some sponsors' Web sites may not be using prices that consumers would actually pay. For example, visitors estimating costs on Humana's Web site last week got a cost calculation based on a drug's national average wholesale price, with no assurance that the price at retail would be the same.
The Bottom Line
To compare four of her PDP choices, Patricia Illemszky of Arlington created an Excel spreadsheet. After entering the prices that her Rite Aid pharmacy charges for the eight drugs she takes for high blood pressure, glaucoma and other conditions, she calculated how much she would pay for them under those plans, factoring in premiums, deductibles and cost-sharing fees.
Illemszky concluded that her annual out-of-pocket costs under Aetna's $31.22 monthly premium plan, which includes a $250 deductible, would be $2,166. Under the AARP plan, which has a $25.80 and no deductible, she would pay $2,490 a year.
Illemszky also ran the numbers for two Humana offerings -- its Enhanced plan, selling for $12.98 a month in Virginia, and its Complete plan which carries a $58.18 monthly premium plan. Both are zero-deductible plans, and both turned out to be non-starters, as far as Illemszky was concerned.
"This is what's unbelievable," she said: The lower-deductible plan would cost her $3,757 a year, while the higher-deductible plan would cost nearly $600 less.
"That's a significant differential," said Illemszky, who is 67. "What that means is you pay a higher premium and you get better coverage."
"If I had the money, even though Aetna is cheaper, I'd go with AARP," said Illemszky, who has had hospitalization insurance with AARP for years, and "they have been great -- never, ever any problems."
But Illemszky said she'll probably not join any plan right now: She doesn't have money to spare, and she earns too much to qualify for assistance. Illemszky may know more about the program than most, but she's not alone in being undecided about enrolling. According to a survey conducted last month for the Kaiser Family Foundation and the Harvard School of Public Health, 61 percent of seniors said they understood the drug benefit "not too well" or "not at all," and 43 percent said they had not yet decided whether to join a plan. One-fifth said they would enroll and more than a third said they would not.
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