doughnut holes

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Millions of Seniors Facing Medicare 'Doughnut Hole'

By Lee and Levine

Washington Post Staff Writers

Monday, September 25, 2006; A03

Millions of older Americans are confronting a temporary break in

their Medicare drug coverage this month that will require them to

pay the full cost of their prescriptions or face the painful

prospect of going without.

This is the " doughnut hole " in the new Medicare drug benefit that

began in January, and advocates for seniors say there is nothing

sweet about it. Some seniors knew nothing of the coverage gap until

they were hit with a bigger drug bill, advocates say.

" Virtually everyone who calls to say they've been denied coverage,

they're shocked, " said M. , president of the Medicare

Rights Center, a nonprofit that helps seniors navigate

Medicare. " Trying to explain that this is the way the program was

created by Congress angers folks who think it makes no sense. Many

people feel blindsided. "

The coverage gap was one of the most contentious elements of the

2003 legislation that created the new benefit. It ends federal

payments for a person's drug purchases once an annual spending limit

is reached, resuming them only after the beneficiary has spent

thousands of dollars out of pocket.

Proponents saw the unusual setup as a way to provide some help to

all beneficiaries, and substantial help to those with catastrophic

drug costs, and yet not break the bank in a federal program that is

expected to cost hundreds of billions of dollars over the next

decade.

Nine months into the program, as more and more seniors reach the

threshold that puts them in the gap, many see it as a headache -- or

worse.

Frances Acanfora, 65, had been paying $58 for a three-month supply

of her five medications. But this month the retired school lunchroom

aide learned that her next bill would be $1,294. She had entered the

doughnut hole.

" It's not my fault that I take this medicine, " the Brooklyn resident

said. " I've got to take it. And they make a limit. That's not fair. "

After talking to her doctor, Acanfora decided to temporarily stop

taking a drug as part of her treatment for breast cancer. She hopes

to obtain some free samples of eye drops for her glaucoma. Three

other medicines -- for high cholesterol, diabetes and osteoporosis --

cost $506.62, which Acanfora put on her credit card.

" I pay a little bit at a time, " she said. " What am I going to do? I

need it. . . . Sometimes, just to think about it, I cry. "

About 3 million of the 23 million Americans who receive the Medicare

drug benefit are expected to reach the gap this year, officials

said. That is fewer than half the 7 million cited in a 2004 report

by the nonprofit Kaiser Family Foundation, which Medicare chief Mark

B. McClellan called outdated.

A few more-expensive plans have no doughnut hole, and low-income

beneficiaries can receive extra help from Medicare that eliminates

the gap. Under the standard plan, however, the government picks up

the bulk of drug costs only until the beneficiary and the government

together have spent $2,250 for the year. At that point,

beneficiaries must pay 100 percent of costs until they have spent a

total of $3,600 of their own money. Then the federal subsidy

resumes, paying 95 percent of any additional expenses.

Beneficiaries must continue to pay premiums averaging $24 a month,

even in months when they are on their own. The calculation starts

anew every year.

At Iona Senior Services in the District, DeYoung's phone keeps

ringing. On the other end are Medicare beneficiaries who have

suddenly fallen into the gap and are looking for ways to climb out.

DeYoung, Iona's community outreach coordinator, has only a few tips:

mail-order pharmacies, diligent comparison shopping, purchases from

Canada.

" For most of them, they're not going to get out of it this year, " he

said. " I don't think everyone really appreciated the doughnut hole,

or they thought it'd be narrower than it is. "

town retiree ce, who says she selected an AARP-

affiliated drug plan without doing much research, now pays " a

fortune " for nearly half a dozen prescriptions. One drug went from

about $84 for a three-month supply to $670.56 -- more than $7 per

pill.

" It was such a shock. I had no idea, " she said. " It's just a hard

pill to swallow, no pun intended. "

Even with the doughnut hole, most beneficiaries are better off

financially than they were before the drug benefit was created, when

many seniors had to fend for themselves all year long.

McClellan said seniors in the coverage gap should continue to use

their Medicare drug cards to get the prices negotiated by their

plans. They also can apply for prescription-assistance programs run

by many states and pharmaceutical companies, he said. And they can

call Medicare at 800-633-4227 for information and help.

" There are lots of places to go to get lower-priced drugs, to get

additional help with your drug costs, " he said.

Mark Merritt, president of the Pharmaceutical Care Management

Association, stressed that the majority of seniors will not reach

the gap. Many who will could delay it by more than two months by

switching to generic drugs and using mail-order pharmacies, he said.

" There's been a lot of hand-wringing about it and very little

information about what people can do to stay out of it, " said

Merritt, whose organization represents companies that administer

drug benefit programs for employers and health insurance carriers.

Another thing seniors can do is choose their drug plans more

carefully for 2007 when the open enrollment period begins Nov. 15.

Knight, director of the Senior Health Insurance Program in

Anne Arundel County, said she and other workers will begin visiting

centers and programs for seniors next month, the start of what is

likely to be another major marketing season for companies offering

prescription coverage.

Many Democrats in Congress, long critical of the gap, are not

waiting until then. They dubbed last Friday " doughnut hole day, "

saying it was when the average Medicare beneficiary would reach the

gap. They and their supporters criticized the policy at dozens of

events last week, airing grievances from seniors in public forums

and delivering edible doughnut holes to the office of at least one

House Republican.

" This gap does not have to exist, " said Sen. Debbie Stabenow (D-

Mich.).

Clarice Wansley, 67, a retired county administrator who lives in

Hattiesburg, Miss., fell into the doughnut hole in June. Her drug

bills went from $184 a month to $387 for the eight medications she

takes for cancer, heart trouble, seizures and other ailments, she

said.

She paid on her own for the past few months, but recently her doctor

told her she needed yet another drug, one that costs $239 a month.

Now she doesn't know what to do.

" I'm not destitute, but I can't pay that and buy gasoline and food

and pay the mortgage, " Wansley said. " I'm scrambling around trying

to find help. "

Dan Wojehowski, 47, of Smyrna, N.Y., takes six drugs for disabling

depression and severe back problems. Last year he was able to get

five of them free through drug companies' patient-assistance

programs. But when the Medicare benefit started, many of those

programs sent people there instead. Wojehowski began paying $53 a

month for most of his drugs. Next month, his first in the doughnut

hole, he will have to pay $341.

Wojehowski, who knew about the gap, plans to continue with two

medications but not the others.

" I just can't afford to buy them, " he said. " Every time somebody in

Washington says what a wonderful benefit this is, I think they have

to look a little closer. "

© 2006 The Washington Post Company