The Medicare Drug Benefit Once Again

Robert Pear--who knows these issues in a way he doesn't know budget issues--files a good report:

In Texas Town, New Drug Plan Baffles Patient and Provider Alike - New York Times: By ROBERT PEAR: McALLEN, Tex. — In Washington, Bush administration officials say Medicare's new prescription drug program is humming along smoothly, filling more than three million prescriptions a day and cutting costs by an average of 50 percent for each beneficiary. But here in the Rio Grande Valley, the picture is different.

Many patients say they have difficulty getting the drugs they need. Pharmacists, swamped with questions and complaints from beneficiaries, have run into many practical problems as they try to navigate a complex program administered by dozens of prescription drug plans, each with its own policies and procedures. Doctors and pharmacists are struggling to figure out which drugs are covered by which plans.

"Intellectually, the program is a good idea," said Dr. E. Linda Villarreal, a former president of the Hidalgo-Starr County Medical Society. "But there's been total chaos and confusion among most of my patients, who do not understand the system and how to work it."... Jose M. Flores, a Medicare beneficiary who lives outside McAllen, used the new drug benefit four times from January to April to purchase Byetta, an injectable medicine for diabetes. Each time he paid $40. So when he went to the pharmacy on May 25, he was dismayed to be told that he owed $167.56 for the next month's supply. Mr. Flores had reached the notorious gap in Medicare's drug coverage. He had to pay the full price of Byetta. His Medicare drug plan paid nothing. "It's almost useless," said Mr. Flores, a 66-year-old school bus mechanic who was interviewed at his home in La Joya, Tex. "I'm paying the premium, but not getting protection."

In coming months, millions of beneficiaries will have similar experiences, as the cost of their drugs reaches the initial coverage limit of $2,250. Like Mr. Flores, they will have to pay the full cost of each medicine until their out-of-pocket costs reach $3,600. At that point, Medicare coverage resumes, paying 95 percent of the cost of each prescription....

Mr. Flores is angry with Medicare, with his drug plan and even with the pharmacists who try to help him. He says no one told him about the coverage gap when he signed up. Vanessa M. Recio, a pharmacist at Saenz Medical Pharmacy in Mission, Tex., said: "All I do all day is talk to angry patients. I process insurance claims and try to solve problems with Medicare."...

Competition among Medicare drug plans drove down premiums, but has complicated operation of the program. Pharmacists here say that most of their low-income Medicare customers have insurance cards from several Medicare drug plans. "They come in and ask, 'Which card should I use?' " said John P. Calvillo, a pharmacist at the Cornerstone Pharmacy in Edinburg, Tex., outside McAllen. That question is not always easy to answer. "Doctors and pharmacists often have trouble finding out what drugs are on the formularies," Mr. Calvillo said. "It's a crapshoot every day."

Typically, a doctor writes a prescription, and the patient takes it to a pharmacist, who submits a claim to the insurer. In many cases, the doctor learns the drug is not covered only after the claim is rejected. The doctor and the pharmacist may repeat the process three or four times until they find a drug that is covered. "This is a huge problem," Ms. Recio said. "In many cases, when doctors write a prescription, they do not have a list of what medicines are covered. They don't even know what plan the patient is in."...

Many doctors are eager to help patients. A few use handheld devices loaded with the formulary for each plan. Some check the Internet to see which drugs are covered by a particular plan. But others said they did not have time to do such research...