Bill Smith, 76, helps his wife of 57 years Martha, 75, take some water with her six medications at 6 a.m., as they do together each morning. Between them, they take 16 drugs each day. To pay for their medications, Bill works part time at the LOA Area Agency on Aging.
Medicare Part D: The Doughnut Hole
• Participants choose a prescription drug plan and pay an average premium of $25 a month ($300/year).
• Participants pay the first $275, called a deductible.
• After that, Medicare pays 75 percent of costs between $275 and $2,510 in drug spending, and the participant picks up 25 percent of the cost.
• After drug spending tops $2,510, participants pay 100 percent of drug costs. This so-called “doughnut hole” or coverage gap applies until they reach a total of $5,726 in drug costs. Then coverage resumes.
• Medicare will then pay 95 percent of the costs of drugs for the remainder of the calendar year.
(Source: Roanoke’s LOA Area Agency on Aging)
Bill Smith doesn't want to leave his invalid wife home alone every weekday morning for five hours, but he has to. Though the 76-year-old retired concrete worker has Social Security benefits and a pension, he still has to go to work every day as a maintenance man -- to afford the medications he and his wife need.
Between them, they take 16 drugs each day. Next year, with estimated increases in Medicare Part D, he'll spend more than $5,000 out-of-pocket for those prescriptions -- not counting the more than $8,000 he'll pay for Medicare medical and supplemental insurance policies.
Talk to any person who's working this month with a senior struggling to re-enroll in the government-subsidized, privately operated prescription drug plan for seniors, and most of what you hear is bad news:
In order to figure out which of the 52 plans in Virginia is cheapest for the drugs the senior takes, a person needs to go to Medicare's Web site and enter those drugs into the Medicare Plan Finder. The problem is, only 32 percent of people over 65 have Internet access.
That means that most have to rely on one of their children or a neighbor or even a pharmacist to do it for them. "If we as geriatric professionals can't understand this information, how in God's name do you expect an 85-year-old to?" said Cathy Thompson, older adult services director of Family Service of Roanoke Valley.
If they can get an appointment, seniors can also call upon LOA Area Agency on Aging's senior services coordinator Elaine Engleman and her team of retired accountant types to do the complicated computer work for them.
"Last night's voice mail alone, there were 38 calls requesting appointments," Engleman said earlier this week. "We're already scheduled through to Dec. 17." The deadline to re-enroll is Dec. 31, although the National Senior Citizens Law Center has warned that enrollment should be completed by Friday for the changes to take effect at pharmacy counters by Jan. 1.
Expanding 'Doughnut'
Two clients have cursed at Engleman after she's given them the news about their Plan D cost increases. Many have left her office in tears. Premiums and co-payments for most plans have jumped at least 25 percent, and fewer brand-name medicines are covered.
A huge hitch for many is the so-called "doughnut hole," which gets bigger next year. It's a gap in the coverage that occurs when a senior's drug purchases reach the annual Medicare spending limit. Then, the senior has to pay 100 percent of medicine costs. Coverage resumes only after the senior has spent $4,050 out-of-pocket.
One low-income senior with dementia was so confused by the term that she offered to bring in actual doughnut holes from the grocery store to meet with Engleman, along with her Kroger bag full of pill bottles.
Last year, Bill Smith's co-workers at the LOA office watched him walking around during the doughnut-hole period "like he had a knife stuck in his stomach," recalled Shannon Abell, LOA's senior services director.
Smith's doctor had prescribed two Nexium pills a day to combat his acid reflux condition, but his Part D coverage would pay for only one a day.
As Thompson at Family Service puts it: "People aren't kidding when they ask us, 'Do I eat or do I take this medication?' "
Cutting Pills in Half
Retired railroad manager Jim Vonderhaar foresaw the confusion and worry. "It was only a matter of time before the companies raised their rates; they went in low to get the market share," said Vonderhaar, an LOA volunteer.
"Medicare gets a bad name and I wish it was simpler, but I don't know what some people would do without it," he added.
U.S. Rep. Bob Goodlatte, R-Roanoke County, said his offices have received only a handful of complaint calls related to the program. "The fact of the matter is, this is a dramatic improvement over where they were prior to passage of the legislation," Goodlatte said.
About to enter its third year, Medicare Part D was designed for people 65 and over who didn't already have private drug coverage. It was complicated, Vonderhaar said, but it worked for the first two years because he could locate plans for most seniors that covered brand-name drugs and didn't have a doughnut hole gap in coverage.
This year, there aren't any such plans. "There are 15 plans that cover generics during the gap, but no plan covers all brands during the gap," Vonderhaar said. He helped one couple enroll earlier this week; both husband and wife suffer from multiple sclerosis and require the same drug, which costs them a total of $3,280 -- for one month.
"Some people are getting their doctors to write different dosages [for double strength] and then cutting the pills in half," Vonderhaar added.
"Or they're only taking half as much as they need to stretch it out."
Canadian Drugs
Pharmacist Tim Schirm of West Pharmacy in Roanoke has a customer with a heart condition who requires two $700-a-month drugs -- and is currently in the doughnut hole.
"I called the doctor's office to see whether she could get samples, or they could get her set up on a program with the manufacturer to get her through to the beginning of the year," he explained. "But at this point we're still waiting to hear back, and she's off her medication."
This year, Betty and Edwin Heptinstall of Vinton have spent $7,189 on their medications -- including Part D premiums, co-pays and doughnut-hole costs. Next year, their meds will cost them $8,400. "I know we live in a great country, but I do think it could be kinder to seniors who have worked all these years," said Betty Heptinstall, a 79-year-old retired bookkeeper.
Roy Caldwell of Roanoke said he found a way to lessen his expenses when he hit the doughnut hole in June: He ordered his four most expensive prescriptions through a Canadian-owned mail-order company-- at one-fourth the cost of what he would have paid using his Part D plan at a local pharmacy, he said.
"Maybe I'll try that, too," Bill Smith said, taking a copy of Caldwell's Rx Care Canada brochure (available by calling 866-479-1669).
Goodlatte said he encourages seniors to navigate the doughnut hole by ordering cheaper, foreign-made medications. He also urges seniors to seek out generic drugs and drug company-sponsored charity programs.
"Quite frankly, when I meet with seniors groups and so on, there is obviously a certain percentage of the population who because of the doughnut hole or a few other problems are not happy. ... But when seniors were surveyed about this [in prior years], the satisfaction rate has been up into the 85th percentile," Goodlatte said.
But Engleman says no one has left her office happy about the 2008 plans. One couple came to her office distraught because they want to get married. The problem: If they marry, their combined income will put them slightly over the cutoff for qualifying for a low-income Part D subsidy.
"I suggested that maybe it was OK for them to just keep living together," Engleman recalled. "The woman said that God wouldn't approve. I said, 'Yeah, but God didn't know Medicare Part D was coming down the pike.' "
Navigating Medicare Part D
Call LOA Area Agency on Aging at 345-0451 to see about setting up a free appointment for help re-enrolling.
The LOA also has satellite help stations with limited hours at the Roanoke City Health Department and in the community room at WDBJ (Channel 7) but desperately needs area companies to volunteer space with computers and Internet access during the re-enrollment period. Call Elaine Engleman at 345-0451 if you can help.
If you’re single and make less than $15,315 a year ($20,535 for a couple), you may qualify for a low-income subsidy, but some limitations apply. To apply at the Social Security Administration office, call (800) 772-1213 or 857-2190. Applications can be accepted over the phone, in person at the office or on the Web at socialsecurity.gov
Once you determine which plan is cheapest, be sure to check for limitations such as prior authorization and quantity restrictions.
Go to medicarerights.org for more information, or call (800) 333-4114 Monday through Friday from 9 a.m. to 6 p.m.
Telephone help is available 24/7 from Medicare at (800) 633-4227; before calling, have your Medicare card and your pill bottles in front of you. During busy periods, callers can provide callback numbers and should receive a return call within 24 hours.