Part D gap straining some seniors' wallets

If you don't watch out, you might fall in.

The gap in coverage for most people using Medicare Part D is nicknamed the "dough?nut hole," because of its ability to swallow up disposable income.

Part D pays 75 percent of initial drug costs up to $2,250 after a $250 deductible for most seniors. But then the program pays nothing until drug expenses reach $5,100. After that, the program pays 95 percent of all costs.

The $2,850 in the middle comes directly out of the patient's pocket. And sometimes it hurts.

"I was getting my prescriptions at a reasonable rate, I thought, but when I went into that doughnut hole it was full price," said retired carpet salesman Doyle Sample of Cape Girardeau.

"It kind of caught me by surprise because I wasn't paying attention."

Medication plays a large role in Sample's life. He said he takes medicine for blood pressure, heart problems, gout and diabetes.

Sample said that prior to reaching the doughnut hole he spent about $250 per month. After reaching the hole, that sum almost doubled to between $450 and $500 monthly for three months' time.

Since surpassing the upper threshold in September, Sample has spent less than $100 monthly.

"It's unreal. I think there should be something done about the doughnut hole because it really did work a hardship on us. We're seniors, so our finances are pretty well set."

But despite his reservations about Part D, he says he has saved about $2,000 per year compared to his previous insurance.

Common miscalculation

Sample is not unusual in miscalculating when he fell into the hole. Ben Tally, manager of Medicap Pharmacy at 1020 N. Kingshighway, said about 90 percent of seniors at his pharmacy who fall into the hole are surprised about it.

Tally said most prescription drug users keep track of expenditures, but aren't sure what costs add up to $2,250.

"I think if the plans were more open and told the folks this is what you have, this is where you hit the doughnut hole and this is what goes into comprising it, a lot of the folks could keep track of it," he said.

Tally said some plans include premiums and deductibles as part of the total, others do not.

Next year the gap will be $3,051, and by 2013 it will be more than $5,000. The total number of available plans in Missouri, now 41, will grow to 53 in 2007.

Wednesday was the first day Part D participants could register to switch plans. More plans in 2007 offer doughnut-hole coverage.

Some seniors say they have found ways to avoid the pitfall.

Marilyn Kinsey, 74, of East Cape Girardeau, Ill., entered the doughnut hole in September. The retired seamstress said when she approached the mark her doctor recommended she switch to generic pills for her blood pressure.

The switch meant the cost of her medications stayed relatively stable. Overall, she estimates Part D will save both her and her husband more than $8,000 this year.

"It's made a big difference for us," she said.

"I'd prefer not to have that hole there, but well, that's life. And because of the difference in drugs my husband won't even reach the hole."

Generics, though, aren't an option for everyone. Many popular drugs are not available as generics. Families USA, a national watchdog group, calculates 18 of the top 25 drugs seniors use are not available in the United States as generics.

Ruth Dockins of the Area Agency on Aging has helped counsel many local seniors with coverage-gap difficulties.

"Sometimes people have to turn to their church or their family or someplace like that for assistance because there just isn't enough money to pay for it," Dockins said.

"But what we tell people is that if somebody has enough expenses that they reach the doughnut hole in a hurry, they're going to get on the other side of it in a hurry as well."

Dockins says she often advises people to go to a Web site called needymeds.com where patients can purchase drugs directly from manufacturers.

She also points to a 2-month-old program from Wal-Mart that sells 143 generic drugs for $4 per prescription.

Despite its warts, Dockins believes Part D has been a big help. "It used to be some people's entire lives were one big doughnut hole," she said.

Another option for those struggling with out-of-pocket expenses is the Missouri Rx Plan created last year.

The plan pays for 50 percent of all out-of-pocket prescription costs for those eligible. Income cut-offs for the plan are $19,600 for single applicants and $26,400 for married applicants.

Nov. 1 marked a new sign-up period in which state officials hope 60,000 eligible but unregistered Missourians will take advantage of the plan.

"It offers a tremendous benefit for those needing help with all out-of pocket costs including deductibles, co-pays and any doughnut-hole gap," said deputy lieutenant governor Eric Feltner.

tgreaney@semissourian.com

335-6611, extension 245