Medicare recipients hitting 'doughnut hole'

By JOSIE HUANG, Portland Press Herald Writer

Copyright © 2006 Blethen Maine Newspapers Inc.

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Staff photo by John Patriquin Lou Bennett, 77, rests at her South Portland home Monday. Bennett, who has a spinal condition, spends more than $750 a month on prescriptions.

WHERE TO FIND HELP MEDICARE'S WEB SITE, www.medicare.gov, and its 24-hour toll-free number, 1-800-MEDICARE (1-800-633-4227), have information to help people choose a plan. FOR HELP IN MAINE, call the Southern Maine Agency on Aging at 1-800-427-7411 or go to www.smaaa.org. Or call the Maine Office of Elder Services at 1-800-262-2232 or go to www.maine.gov. THE NEXT enrollment period will be in November. THE 'DOUGHNUT HOLE'MEDICARE beneficiaries who have used $2,250 in prescription drugs hit a coverage gap known as the "doughnut hole." COVERAGE resumes once they have used $5,100 in drugs, including $3,600 of their own money. To top of story

For her 77th birthday a week ago, Lou Bennett asked her children for help with prescription costs even though she has a drug benefit through Medicare.

Coverage had stopped because just six months into the plan, she had used $2,250 in drugs - paid for with $750 of her own money and $1,500 from insurance. Coverage will not resume until she spends another $2,850 on her own, bringing her out-of-pocket cost to $3,600.

Bennett, of South Portland, always knew she would hit the limit - just not this soon. "I think I was somehow in denial about how much this would impact my finances," she said.

Sticker shock is greeting the first of the elderly and disabled Medicare recipients to reach the coverage gap, commonly known as the "doughnut hole." The $2,850 gap was built into the new prescription drug coverage to get consumers with above-average expenses to help foot the bill.

Now, as more people join Bennett in the hole, pharmacists and advocates for seniors in Maine expect anger and confusion similar to what happened when startup glitches in January left people with spotty or no coverage.

Part of the problem lies in the complexity of the Part D drug benefit, said Carol Rancourt, an elder advocate with the Southern Maine Agency on Aging in Scarborough.

A few plans offer partial coverage during the coverage gap, but some beneficiaries who felt pressured to pick a plan and avoid a late penalty focused more on immediate costs such as deductibles and premiums, Rancourt said.

Others thought the doughnut hole kicked in once they had contributed $2,250 toward drugs, she said.

"This is a very complicated law for people to understand," said Rancourt, who has taken calls daily from seniors asking her what to do. One man told her he cut back on his daily medications after reaching the limit.

For Bennett, a former psychotherapist, picking a plan was so overwhelming that she chose one from AARP simply based on name recognition. It does not cover an arthritis drug that retails for $168, adding to her burden.

An estimated 3 million to 7 million Americans will hit the gap this year. They are a minority of the 30-million-plus beneficiaries with drug coverage through Medicare, other government programs, or an employer, but they are among the sickest. The poorest in this group will receive state assistance. But lower-middle and middle-class Medicare recipients will be on their own.

The federal Medicare agency urges such individuals to talk to their doctors about switching to generic drugs or less expensive brand-name drugs.

"This will slow down the pace of their own out-of-pocket spending and could alleviate costs for some of the beneficiaries approaching the doughnut hole," said Roseanne Pawelec, spokeswoman for the Centers for Medicare and Medicaid Services in Boston.

But Christopher Gauthier of the Maine Pharmacy Association cautions that there is not always a clinical equivalent for a particular drug, in which case the patient will have to swallow the cost, drop the drug, or choose a less effective replacement.

Gauthier said he and his colleagues have not seen a lot of customers reach the doughnut hole, but are anticipating an uproar worse than the confusion caused by the Medicare drug program's launch Jan. 1.

"You're going to have the same people who were frustrated with the initial sign-ups to begin with, and are now at the point where things are finally rolling," Gauthier said. "All of a sudden you're going to cut their benefit again."

Pawelec said the doughnut hole is necessary for Medicare to cover the majority of people who will not hit the limit, and those with catastrophic drug costs. The latter should blast through the doughnut hole. Once out, Medicare would start to cover 95 percent of drug costs.

Groups around the country, including the Maine People's Alliance, have argued that the savings could be produced by allowing Medicare to use its bulk purchasing power to negotiate drug discounts.

In all likelihood, Bennett will get out of the hole before year's end. She is spending more than $750 a month on seven prescriptions to treat her spinal condition, heart disease and asthma.

Bennett said if not for the generosity of her children and her housemate, she would be in "deep trouble." Now she is looking for a plan that covers all her drugs. "I'm going to study very carefully and find out what my options are," Bennett said.

Staff Writer Josie Huang can be contacted at 791-6364 or at: