At least 3 million Americans who enrolled in a Medicare prescription drug plan this year can expect to see their benefits vanish when their drug costs hit $2,250.

Michigan, USA. July 17, 2006 (Detroit Free Press)


Don't be caught off-guard.

It's not too late to avoid the frustration of falling into the Medicare coverage gap known as the doughnut hole. Once in the hole, seniors must pay 100% of a drug's retail price instead of copayments that range from $5 for generic drugs to $30 for a brand-name prescription.

Counselors who work with the nation's senior and disabled citizens anticipate confusion and anger as more Americans see their pharmacy costs climb even as they continue to pay their monthly premiums.

To reduce the angst involved in dealing with higher out-of-pocket costs, Medicare Administrator Mark McClellan said consumers can use low-cost generics so that it takes longer to get to the doughnut hole.

Enrollees could put aside money before they reach the gap to help cover higher costs. The average enrollee is expected to hit the hole in September or October. But some people who have particularly high drug costs, such as Bloomfield Township resident Ardemis Kalousdian, have fallen in already.

Kalousdian, 89, surpassed $2,250 in drug costs last month. Under her plan, she'll have to pay $2,948 before her Medicare drug plan covers her costs again.

But she's lucky, she said. She did her homework before she signed up for a plan.

Kalousdian spent about $5,500 on medicines last year. She's taking even more this year: Her daily dosage includes more than a dozen medications. And prices have gone up.

Last month, while her drug plan was still footing some of the bills, Kalousdian believes she spent about $280 on copays. That's less than last year's average monthly bill of $460.

Now that she has fallen into the hole, Kalousdian knows her costs will go up, but she has a plan.

Instead of going to the pharmacy once a month to fill all of her prescriptions, she's staggering her visits to spread her costs out over time. Despite the doughnut hole, she believes her prescription plan will save her money.

Kalousdian is confident she'll emerge from the other side of the hole and reap the catastrophic-coverage benefits. Catastrophic coverage will kick in after she has used $5,100 in drugs, including $3,600 of her own money. At that point, her drug plan will pick up 95% of her drug costs and she can expect to pay $2 a month for each generic prescription and $5 a month for brand-name drugs.

For those who can expect to come out of the hole and get catastrophic coverage, it's important to remember to use a plan-approved pharmacy and show your drug-plan card every time you fill a prescription, said Carrie Nicholson, Medicare-Medicaid assistance program coordinator at the Area Agency on Aging in Southfield. Only under those conditions will the money enrollees spend during the coverage gap count toward meeting the catastrophic-coverage limit.

Additionally, beneficiaries still may receive lower prices for their drugs than they would without the card because most insurance plans negotiate discounts for their members.

For enrollees who spend at least $2,250 on drugs but don't expect to use $5,100 worth, the situation becomes more complicated, Nicholson said.

Those people may want to consider going to the least expensive drugstore, regardless of whether it's in the plan's network. Some people might want to shop to see whether their medicines are available for less in Canada. Neither type of purchase would contribute to the out-of-pocket spending necessary to emerge from the hole.

Theresa Kidd, program specialist at the Michigan Medicare Medicaid Assistance Program, said people who got advice before they chose a plan should know about the doughnut hole.

Still, many of them are not happy about it, Kidd said.

Sister Mary Ellen Howard, director of the Cabrini Clinic in Detroit, said she doesn't believe most beneficiaries understood the Medicare drug benefit when it took effect this year.

"I keep waiting for a senior uprising when they hit the doughnut hole," Howard said.

### Source: Detroit Free Press