Medicare Doughnut Hole: Gov. says "Here's Some Help for Your Drugs...Syke"

4/27/2006, 12:07 a.m. PT
By KEVIN FREKING
The Associated Press

WASHINGTON (AP) — Mildred Lindley is stuck in a hole, the doughnut hole — "right in the middle of it," she says — that comes with Medicare's new prescription drug benefit.

Just four months into the program, Lindley has hit the point in her coverage where she has to pick up, at least for a few months, the full cost of the medication she takes to keep her bone marrow cancer in remission. As a result, her two-month supply of Thalomid shot up from $40 to a whopping $1,300.

"If I can't get it, I guess I'm here until the Lord takes me out. That's all I can do, because there's no way I can afford it," said Lindley, an 80-year-old from Jonesboro, Ark.

"I'm in the hole all right."

Under the standard drug benefit, the government subsidizes the drug costs for seniors and the disabled. But after costs reach $2,250, the subsidy stops until a beneficiary has paid out $3,600 of his or her own money. Then, the government will start picking up 95 percent of each purchase.

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Congress designed the drug benefit to give people some help with their initial drug costs, plus help those who have massive expenses. The doughnut hole was designed to reduce the overall cost of the program and still allow the federal government to meet those two goals.

About 6.9 million Medicare beneficiaries will have to deal with a gap in their drug coverage at some point this year, according to estimates from the Kaiser Family Foundation, a health policy research group.

Medicare officials point out that, even with the doughnut hole, millions of seniors are getting financial help that they never had before. They also stress that the poorest of beneficiaries will get extra help to cover their medications.

However, there are beneficiaries who are convinced they will be worse off, many of whom had relied on free medicine provided by the drug manufacturers. They were told by the manufacturers this year that the free supplies would stop now that they were eligible for Medicare coverage.

Victoria D'Angelo of Denver relied on the patient assistance programs for many of her prescription needs last year. She enrolled in a Medicare drug plan when told by one of those companies that such help would end Jan. 1.

Now, that she's hit the doughnut hole, she's charging some of her drugs to her credit card. She said she'll worry about the ramifications later since she cannot afford to skip taking her Seroquel, which is used to control bipolar disorder.

"Basically, I've been to hell and back on this," said D'Angelo, referring to her disease. "I'm just deathly afraid of getting sick again."

Shirley Rhodes of Gladwin, Mich., figures that while she and her husband, Samuel, are in the doughnut hole, they'll have about $49.67 a month to live on after covering their drug expenses.

For that reason, they will wait until the last possible day to enroll in a Medicare drug plan. In the meantime, she'll continue to ask the pharmaceutical companies to help her out, and she'll work with Social Security officials to figure out how the family might qualify for extra assistance through Medicare.

"If we don't qualify, we will be giving our house back to the mortgage company, and then we'll still owe for the second and third mortgage," Rhodes said.

Some beneficiaries pay higher monthly premiums to make the doughnut hole smaller or do away with it entirely. Also, the poorest beneficiaries don't have to worry about it at all.

Analysts say that most beneficiaries who hit the doughnut hole probably won't get there until the fall.

Mark McClellan, administrator of the Centers for Medicare & Medicaid Services, stresses that the beneficiaries may be able to avoid the doughnut hole entirely by switching to generic drugs or lower-cost brand names.

Consumers Union, publisher of Consumer Reports, says that senior citizens taking five commonly prescribed drugs _for high blood pressure, cholesterol, heart disease, arthritis pain and depression_ could save between $2,300 and $5,300 a year under various Part D plans by switching to lower-cost drugs.

Lawmakers are also pleading with drug manufacturers to continue with patient assistance programs that allowed many low-income people to get free medicine.

"We've got a situation where it looks like the May 15 date has become an excuse for dropping the assistance that many Medicare beneficiaries rely on, and that's not right," said Sen. Charles Grassley, R-Iowa.