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Out of pocket becomes bitter pill

The Baltimore Sun

Coming soon to a pharmacy near you: the hundred-dollar co-pay.

As another enrollment period for Medicare prescription coverage opens - it begins Thursday and lasts until the end of the year - many of the plans are raising premiums, co-payments and deductibles.

The cost increases mean it's important to shop for Medicare prescription plans all over again. Even if you're happy with the plan you have, look closely: The cost of the plan could be quite different next year.

How different? According to a study by the consulting firm Avalere Health, monthly premiums are increasing 21 percent on average for prescription plans, with many of the steepest rises coming in those that have had the lowest premiums.

For example, the popular Humana PDP Standard plan charged a $6.44 monthly premium in Maryland in 2006, the lowest in the state. For 2007, premiums doubled to $13, still one of the lowest. For 2008, the premium will more than double again, to $27.20, more than $11 a month higher than the new lowest-cost plan.

Co-payments - the amount you pay out of pocket for each prescription - are going up as well, particularly for brand-name drugs.

One plan, WellCare Signature, will charge $107 for each brand-name drug not on its preferred list and $45 for a preferred brand name - and no co-pay for generic medications.

While they don't break triple digits, other plans have co-pays for nonpreferred brand-name drugs of $75 and up.

For example, the popular AARP MedicareRx Enhanced plan will charge $76.65.

In addition to the changes in price, two relatively popular plans, SierraRx Plus and WellCare Complete, will no longer be offered at all in Maryland. Members of those should look for new plans.

You have your work cut out for you.

52 plans offered

Fifty-two Medicare prescription plans are being offered in Maryland for 2008, all run by private insurance companies. Each one has different monthly premiums (from $16.10 to $97.50), different co-pays for prescriptions, different lists of covered and preferred drugs, and different networks of participating pharmacies.

The best plan for you isn't necessarily the one with the lowest premium; it's the one that will mean the lowest total cost, over the year, for your medications. The only way to identify that plan is to start with a list of your own medications, including dosage.

You can get a total cost for the year, and see customer service data, on the Medicare Web site ( or by calling 1-800-MEDICARE. You can also get help and advice, and one-on-one shopping help, from local Senior Health Insurance Program (SHIP) counselors in each county and from the Maryland Senior Prescription Drug Assistance Program. (See box listing phone numbers and Web addresses.)

Picking a plan

Here are some pointers on picking a plan:

Watch the doughnut hole.

All plans for 2008 have a "doughnut hole" (known in Medicare-speak as "the coverage gap") where only generic drugs are covered - or there's no coverage at all.

You fall into the doughnut hole when you've filled $2,510 worth of prescriptions (total cost for you and the insurance company), and you're stuck there until your drug costs reach $5,726.35.

Meanwhile, you have to keep paying your premiums. Counting co-pays, deductibles and the doughnut hole, you could pay as much as $4,050 out of pocket. Here's the good news: Once you've spent that much, you get all future prescriptions for a co-payment of $5.60 or less.

Consider the alternative: a full health insurance plan.

In addition to prescription plans, the open enrollment period is a chance to sign up for so-called Medicare Advantage plans. These are HMOs and other full health plans. Many of them include prescription coverage, but some do not. Some offer extra benefits. On the other hand, some limit which doctors and hospitals they will cover. Some, called special needs plans, are open only to certain categories of people, such as those with chronic diseases. A Medicare Advantage plan might be a good deal, but make sure you understand the details of what you're getting into.

Help for those with limited incomes.

Individuals with incomes below $15,315 and couples below $20,535 qualify for a low-income subsidy, known to Medicare as "extra help." (There's also an asset limit.) If you qualify, you pay lower or no premiums and very low co-payments with prescriptions. You need to file paperwork with the Social Security Administration to get the help.

In addition, the Maryland Senior Drug Assistance Program pays $25 a month toward premiums for people with income below $30,630 for an individual or $41,070 for a couple; you need to apply separately to the program.

If you're already getting that help.

Both Medicare and the state assistance program are sending out paperwork to confirm that you still meet the income requirements. Be sure to complete the paperwork - if you don't, you will be charged full price.

While the state program applies to any prescription plan, the Medicare low-income subsidy applies only to plans with premiums below the benchmark for the region.

As plans raise prices, an estimated 1.6 million people nationally and 10,197 in Maryland will not be able to stay in the plan they're in now. Of those, 7,350 Marylanders were randomly assigned to begin with; if you're one of them, Medicare will reassign you if you don't choose another plan yourself. If you're among the 2,847 who chose their plan themselves, you'll need to pick a lower-premium plan or, if you don't, you stay in your current plan but pay the difference.

If you're already enrolled in a prescription program.

If you do nothing, you will continue to be enrolled for another year in the program you're in now. However, the premiums, co-payments and covered drugs may change. You should have already gotten a letter from your plan spelling out the changes. Again, it's worth doing the shopping all over again - the plan that was the best deal for you this year might not be next year.

If you decide to enroll in a new plan, you don't have to do anything to cancel your old one. The Medicare computers do that automatically.

Prescription plan tips

Besides the best price for your medications, here are some things to watch for in choosing a Medicare prescription plan:

Service. Medicare now posts complaint rates and other service scores on its Web site, If plans are close in price, choose one with fewer hassles.

Barriers to prescriptions. Some plans require prior approval - a doctor has to document why you need specific medicines or therapy - and you have to try a cheaper medicine first before they'll pay for the more expensive one you want. If these apply to prescriptions you use, you might want to choose a plan with fewer restrictions.

Deadlines. You have until Dec. 31, but, if you want to change plans, try to do it by the end of the first week of December. If you switch on New Year's Eve, you're likely to have problems getting your prescriptions in early January.

Eligibility. Anyone over 65 or qualified for Medicare through disability is eligible to buy a prescription plan. But if you already have coverage that's as good, such as through a company or union retiree plan, you don't need to sign up, and signing up might cancel your current benefits.

[Sources: Centers for Medicare & Medicaid Services; local offices on aging; Maryland Senior Prescription Drug Assistance Program; Avalere Health.]

Medicare help by phone or online

Centers for Medicare and Medicaid Services, the federal agency that administers the Medicare program. or 1-800-MEDICARE, 24 hours. You can ask about options and enroll by phone or online. Also, national Medicare officials will be conducting two information sessions in Baltimore Tuesday: at the Oliver Senior Center, 1700 N. Gay St., from 10 a.m. to 11:30 a.m.; and at the New Shiloh Baptist Church, 2100 N. Monroe St., from 1 to 2:30 p.m.

Senior Health Insurance Assistance Program: Local SHIP offices run information sessions and do one-on-one counseling. Schedules from local SHIP programs are at For a list of all SHIP programs in the state, go online to or call the state Department of Aging at 410-767-1100 or 1-800-243-3425 . Numbers for SHIP programs in the Baltimore area are listed below. SHIP numbers are generally answered only during business hours.

Anne Arundel County, 410-222-4464

Baltimore City, 410-396-2273

Baltimore County, 410-887-2059

Carroll County, 410-386-3800

Harford County, 410-638-3025

Howard County, 410-313-7392

Maryland Senior Prescription Drug Assistance Program: Information on state premium subsidy for moderate-income beneficiaries, and general help and information on Medicare, 1-800-551-5995 or online at A schedule of information and enrollment events may be found at

Social Security Administration: To qualify for low-income subsidy, 1-800-772-1213, or online at

[Getting help in person]The state senior drug program and many local SHIP offices have scheduled information sessions and enrollment fairs. To see schedules for your county, go to. [What you need to have with you]Whether seeking help on the phone, on the Web, or in person, have handy:

Your Medicare card

A list of all your prescriptions and dosages

The name of your preferred pharmacy

Any letters you've received about your eligibility for an "extra help" subsidy and any pharmacy benefit or discount cards you have currently.

Sources: Centers for Medicare and Medicaid Services, Maryland Senior Prescription Drug Assistance Program, local offices of aging


Submit your questions about the Medicare prescription drug benefit online at or mail to M. William Salganik, The Sun, 501 N. Calvert St., Baltimore MD 21278. Selected questions will be answered by Sun reporter Salganik with responses published in Money & Life Nov. 25 and posted online Nov. 26.

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