“One of the first things we learned about Part D is that it often did not cover all of the medications for those who are chronically ill,” Vargas says.

Seniors with only one or two prescriptions easily found an affordable plan that would help them pay for those medications, but those with four or five high-cost drugs discovered that most plans did not cover all of their prescriptions.

“The intent of the program is a good one,” Vargas says. “But, as is usually the case with any government program, it’s going to take awhile to iron out the wrinkles.”

The initial enrollment period was open until May 15, 2006, to give seniors time to understand the program, apply for extra help and enroll in a plan. With enrollment currently closed, many people are still struggling with the limitations of the plan they selected.

The next open enrollment period begins Nov. 15, and seniors who are dissatisfied with their current plan will be able to switch to a new plan without a penalty. In preparation, there are some things they can do to make the selection process easier.

Consolidate prescriptions “Consolidate all of your prescriptions with one pharmacy,” says Vargas.

Pharmacies have access to a computer program that details the medications covered, or formulary, each plan offers. The program also shows how a plan covers generic versus branded prescriptions.

“It is much easier to select the plan with the best coverage if one pharmacy handles all of your prescriptions,” Vargas says.

Choose a plan based on its coverage
“I talked with people who had chosen a plan based on the cost of the premium,” says Vargas.

While it is tempting to select a low monthly premium, it is more important to make sure that the chosen plan covers the needed prescriptions.

“Each plan has a co-pay and multiple levels,” says Vargas. “I can help people understand what each of these levels means, and the type of coverage they will have under a certain plan.”

Nearly all of the prescription drug plans in North Carolina have three levels. The lowest level within the plan pays for most generic drugs, with a co-pay of $1 or $2. The middle level of the plan pays for certain branded pharmaceuticals, with a co-pay that is generally between $25 and $50. The highest level within a plan pays for branded drugs, but requires a physician’s authorization for the prescription to be filled.

“Insurance companies are using what we call ‘step therapy,’” says Melinda Wallace, medication assistance coordinator with FirstHealth CARES. “They will require you to go through various steps to get approval for certain medications.”

Wallace gives the example of the drug Nexium, which is often prescribed to treat acid reflux. “Suppose your physician prescribes Nexium,” she says, “but your plan covers Protonex. You have to tell your physician that your plan does not cover what he or she prescribed, and ask if you can take the Protonex as a substitute. If your physician wants you to have Nexium, then the physician must fill out an appeals form so that you can have that medication.”

Both Wallace and Vargas point out that this part of Part D has been an additional burden on patients, physicians and pharmacies. It is also why it is important for seniors to understand the type of coverage they have selected with their drug plan.

Understand the ‘doughnut hole’
Part D’s “doughnut hole” represents the absence of drug plan coverage for medication expenses that fall between $2,250 and $3,600 annually.

“People who bought a plan with the bells and whistles aren’t affected by the doughnut hole,” says Wallace. “But those who are not covered, and whose expenses fall into the hole, are having trouble paying for their medications.”

Wallace says that she has met many people who are having difficulty paying for medications because their expenses are currently within the hole’s range.

Under the plan’s current design, Medicare prescription coverage kicks back in once a person’s drug costs exceed $3,600. Then Medicare may pay up to 95 percent of drug costs, depending on the person’s insurance plan.

According to Vargas, there has been some talk about shrinking the size of the hole for 2007, but, as yet, nothing definitive has been announced.

Future enrollment periods
A new enrollment period that opens Nov. 15 and runs until Dec. 31. Coverage starts Jan. 1, 2007. Seniors who were eligible to enroll in Part D during this past year, but elected not to do so, are encouraged to choose a plan during this coming enrollment.

“You can choose a low premium plan, even if you don’t need the coverage,” says Vargas. “It at least gets you into the system.”

“If you were eligible to enroll in Part D, but didn’t, you are incurring a 1 percent per month penalty,” says Wallace. “The penalty for 2006 is calculated on a $32 per month premium, and has been accumulating from May 15, 2006. That penalty continues to be added to any future premium until a person signs up for coverage. The penalty becomes a permanent part of a person’s premium.”

Hope for the future
“There is no question that millions of people have already been helped by this new drug plan,” says Wallace. “But there are still millions of others who are struggling to pay for their prescriptions.”

Vargas echoes Wallace’s observations, and adds a word of hope.

“The program has been confusing, because there is no one-size-fits-all scenario,” she says. “But as we gain experience, it will get better.”