Prescription Ills Seniors in managed-care plans may pay much more for drugs
Rosalie Gregory sits in her kitchen, trying to figure out how she is going to be able to afford co-pays for her leukemia medication under the new senior drug plans. MARTY BICEK/THE BEE By KEN CARLSON BEE STAFF WRITER Last Updated: December 21, 2005, 05:06:50 AM PST While it's touted as a cost-saving program for seniors and the disabled, the Medicare prescription drug program is going to cost substantially more for people enrolled in managed-care plans. About 38,000 Medicare beneficiaries in Stanislaus and San Joaquin counties buy health benefits through Kaiser Permanente's Senior Advantage or Pacificare's Secure Horizons plan. Those residents are being hit with increased premiums and co-payments. And some, such as Rosalie Gregory of Ceres, will pay a lot more for lifesaving medicines. Gregory, who has Senior Advantage, said she paid $30 a month this year for Gleevec, a drug that she takes for leukemia. The medication has put the cancer in remission and she needs to keep taking it. But it will cost her $3,700 next year, and her costs for medicines will go from $640 to $4,024, her family says. Gregory said she doesn't have the money. "As senior citizens, we were all pumped up about how much we were going to save with the Medicare drug program," she said. "It is not saving me thousands of dollars; it is costing me thousands." In 2004 and 2005, Senior Advantage provided unlimited coverage for gen-eric medications, and covered the brand drug Gleevec as an exception. (The retail price for Gleevec is upward of $2,700 for a month's supply.) But Senior Advantage in 2006 is modeled after the new standard Medicare drug plan, and that means Gregory has a coverage gap. The Senior Advantage co-payments for generics will be $30 for a 100-day supply, triple the previous co-payment, and $40 for a 30-day supply of brand- name drugs. If the cost of the drugs reaches $2,250 in a year, subscribers have to pay full price until their out-of-pocket expenses total $3,600. Above that, a "catastrophic coverage" is triggered, requiring monthly co- payments of $3 for generics and $10 for brand drugs. Senior Advantage members also are being hit with a premium increase from $50 to $96 a month, while the Secure Horizons premium is going from $54 to $68. "Where is the savings?" asked Howard Olson, a Modesto retiree who takes medication for his heart. "It is taking an extra $500 a year out of my pocket." Deductibles will be lower Members of Senior Advantage and Secure Horizons, which also has the coverage gap, were warned they would lose their regular health benefits if they purchased one of the 48 Medicare drug plans available in Northern California. Beside coverage for medicines, the health plans provide subscribers with a network of doctors and hospitals and lower deductibles than the standard Medicare program. When Congress approved the Medicare prescription drug program, it created a standard plan for insurers that would offer drug plans in different regions of the country. Jack Cheevers, a Medicare spokesman in San Francisco, said the managed-care plans were required at least to match the standard plan, but can offer enhancements, too. "They can cover all or part of the coverage gap or offer lower premiums and deductibles," he said. Some of the stand-alone drug plans do not have the coverage gap. Those plans generally have higher premiums than others, Cheevers said. One plan offered by Humana, which does not have a coverage gap, covers 400 milligram Gleevec for a $60-a-month co-pay. The premium is just over $50 a month. Kaiser lists benefits Denise Hanson, director of Medicare and state programs for Kaiser, defended the changes made to Senior Advantage. In the last two years, the plan did not cover brand drugs, and it provides catastrophic coverage for people whose medication costs exceed $3,600 a year, she said. Senior Advantage also doesn't have a $250 annual deductible found in the standard Medicare drug plan. "On the whole, it is an improved benefit," she said. An estimated 15 percent of members would be affected by the coverage gap, she said. She added that the increase in co-payments isn't so high for members opting for Kaiser's mail-order pharmacy. Gregory said she is applying to Kaiser's charity care program, but it appears her annual retirement income of $21,000 is too high to qualify. The family also is asking the drug's manufacturer for a break. Geoffrey Cook, a spokesman for Norvatis Oncology, maker of Gleevec, said that nonprofit groups offer assistance for people who can't afford the drug. He cited research costs as the reason for the drug's cost. Cheevers said financial assistance is available for low-income residents who can't afford the coverage gap. Another option for someone like Gregory is to purchase a more affordable drug plan and fall back on traditional Medicare health coverage. If Gregory dropped out of Senior Advantage, she would lose her Kaiser- affiliated doctor. Under Medicare, her copayments for hospitalizations could be $1,000 in a year. And her share of the costs for seeing physicians and specialists would be higher. The managed-care plans also have coverage for glasses and routine eye and hearing exams. Barbara Neer, a retired medical assistant in Modesto, said the new drug program has been confusing even with her background in health care. She and her husband, Richard, have struggled to find out if the medicines they take are covered by their managed-care plan. "They are doubling and tripling the cost, plus it is confusing for the majority of people," Neer said. 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