Medicare Part D sees flurry of late changes

January 22, 2007

As Medicare Part D moves into its second year, the program has undergone modest yet important changes. Still, despite sometimes significant premium increases and lack of coverage in the donut hole, most seniors seem to be sticking with the prescription drug plans (PDPs) they picked last year.

As Medicare Part D moves into its second year, the program has undergone modest yet important changes. Still, despite sometimes significant premium increases and lack of coverage in the donut hole, most seniors seem to be sticking with the prescription drug plans (PDPs) they picked last year.

According to a recent survey from the Kaiser Family Foundation and the Harvard School of Public Health, only 5% of seniors enrolled in Medicare Part D plans expected to switch plans for 2007. "We are very concerned that we don't have the same number of people calling and looking for help with selecting a plan," explained Elana Berman, director of enrollment at the Medicare Rights Center, a patient advocacy group. "It's difficult to know what options seniors have, especially since the plans have changed significantly."

According to Berman, one of the reasons many seniors may not be actively looking to change their plans is that they did not receive "Notice of Change" letters by the Oct. 31, 2006, deadline. Recognizing the problems, CMS announced on Dec. 28, just days before the deadline, that it would extend the deadline to Feb. 14 for some 250,000 beneficiaries of United Healthcare and other PDPs who received the letter after Nov. 15, 2006, or not at all.

Beginning in 2007, a number of pharmaceutical companies will begin to offer patient assistance programs (PAPs) designed to help Part D beneficiaries in the donut hole. PAP plans are offered by drug companies to low-income recipients using specific brand medications. In many cases, the drug company offers its brand medication at little or no cost to recipients. Still, beneficiaries must meet strict guidelines for eligibility and must apply to individual PAPs for each drug separately.

GlaxoSmithKline developed the GSK Access PAP plan that is open to low-income beneficiaries who have spent at least $600 in true-out-of-pocket (TrOOP) expenses. "Even though the Medicare Part D plans have been a great success for many, we know that there are still patients who don't qualify for the government subsidies and may need help in getting their medicines," explained Chris Viehbacher, president of GlaxoSmithKline's U.S. Pharmaceuticals business, in a written statement.

Many other drug companies, including Johnson & Johnson, AstraZeneca, Wyeth, Merck, and Novartis, have also adapted existing PAP plans to cover Medicare Part D beneficiaries. Still, some advocates question whether the plans will actually help Medicare Part D seniors in the donut hole. "It's really just a Band-Aid for specific people on specific medicines," contended Berman.

In 2007, most Medicare Part D recipients will reach the donut hole after they have spent $2,400 in TrOOP expenses. Beneficiaries will have to pay the next $3,850 in drug costs before catastrophic coverage kicks in. Some Part D PDPs have changed to offer limited coverage in the donut hole, although it is usually for generic drugs only.

Berman pointed out that any expenses related to acquiring medications through PAP plans will not count toward the donut hole and may actually make it more difficult for beneficiaries to reach catastrophic coverage. Still, others note that with several Part D PDPs now covering only generics in the donut hole, the PAPs may help low-income beneficiaries gain access to expensive brand-name medications they otherwise would not be able to afford.

Resources for coverage in the Part D donut hole

With hundreds of patient assistance plans established by the states as well as pharmaceutical companies, a number of Web sites have emerged that help patients and healthcare professionals determine which plans might work and the eligibility requirements. Most sites can be searched by individual drug or by state. Below is a short list of sites, with the sponsor listed in parenthesis.

http://www.pparx.org/ (Partnership for Prescription Assistance, a consortium of pharmaceutical companies)