Sandusky resident Velma Price is one of many Medicare beneficiaries who have found themselves in Part D's "doughnut hole," struggling to pay for prescriptions.
The 60-year-old fell into the doughnut hole unexpectedly in March when she went to pick up her prescriptions and was shocked to find the total was hundreds more than she was used to paying.
"I was panicking," Price said. "I didn't know what to do."
She left the pharmacy empty-handed that day, unable to pay for her prescriptions.
Price now takes her medications every other day instead of daily, and sometime goes without medication for a month at a time. Then there are the days when Price chooses between buying groceries or the medication she desperately needs.
Price suffers from diabetes, heart disease, fibromyalgia and severe arthritis. She had a stroke in 2005 and suffered a heart attack in December. Her total monthly drug cost is more than $800.
"I never thought I would be in this situation," the former nurse said.
She's not alone. When Medicare Part D prescription coverage was introduced in 2006 as the answer to senior prescription woes, Medicare beneficiaries flocked to sign up. Confused by the dozens of plans offered in Ohio, many signed up for coverage that didn't best meet their individual needs. This year, 27 companies are offering 61 prescription plans.
According to the Ohio Department of Insurance, the doughnut hole is the gap in coverage that generally occurs once a senior receives $2,400 worth of drugs. At that time, insurance stops paying a share of the senior's monthly drug costs until the senior spends a total of $3,850 out of pocket. Once the senior spends that much, coverage kicks back in, with insurance paying about 95 percent of the senior's drug costs for the remainder of the calendar year.
Sixteen of this year's plans offer some coverage for generics during the doughnut hole. Only one plan - which has the highest monthly premium of $95.90 - offers some coverage for brand name drugs during the gap.
"It's almost a big joke," Price said of Medicare Part D, adding that she read through all of the paperwork and was convinced she chose the right plan.
Serving Our Seniors has been helping Price and other seniors in the same predicament find ways to ease the financial burden. Price receives about $400 in monthly assistance through the Erie County agency.
Serving Our Seniors Executive Director Sue Daugherty said the Medicare program isn't trying to trick seniors, but the programs are so complicated it is easy for people to get confused, or think they understand a program's policies when they don't.
She saw it last year and she's seeing it this again year as seniors start hitting the doughnut hole. The agency estimates that up to 30 seniors it serves will hit the doughnut hole this summer. It is unknown how many of the state's 1.2 million prescription plan enrollees are headed for the same fate.
Daugherty urges seniors to talk with their pharmacists, doctors and local senior centers about ways to manage during the coverage gap and how to avoid it next year when signing up for 2008 coverage. She said she hates to see seniors making choices between medication and other necessities.
"It's a struggle everyday," Price said.
Cheryl Welch 5/19/07 PULLOUT
What is the Medicare Part D doughnut hole?
* The doughnut hole, a gap in coverage, is found in most Part D prescription drug plans offered in Ohio.
* Typically, seniors hit the doughnut hole once their total drug costs - what they and their insurer pay - reach $2,400 during the calendar year.
* Then the insurance coverage stops. The senior has to pay 100 percent of their drug costs between that $2,400 and $5,451.25.
* Once the senior's total drug costs reach $5,451.25 and they've paid about $3,850 out of pocket, coverage kicks in again.
* From then on, insurers pay 95 percent of drug costs, leaving seniors paying 5 percent of the cost or $2 for generic drugs and $5 for brand-name drugs, whichever is greater.
* For questions, call the Ohio Department of Insurance at 800-686-1578, visit ohioinsurance.gov/prescriptiondrugs/index.asp or contact your local senior center
Source: Ohio Department of Insurance