Before Sue Russell signed up for Medicare's prescription drug benefit program, a three-month supply of Plavix cost her $425. Now, the Mt. Juliet resident pays only a $96 co-payment every time she buys the blood-thinning drug.
"When we got this card, it was just like I had a raise," said Russell, who's retired.
The cost dropped after Russell signed up for the Medicare benefit launched in 2006 that absorbs the lion's share of prescription drug costs.
But not all eligible beneficiaries are taking advantage. An estimated 133,000 Medicare recipients statewide have not enrolled in the program, despite not having any other drug coverage. That's nearly 14 percent of the 980,000 people statewide eligible to enroll in the program also known as Medicare Part D.
They include people like Barbara Tanner, a Nashville woman who figured she couldn't afford premiums on the drug plans that are offered through private insurers. Tanner, who went on Medicare eight years ago because of a disability, estimates that she pays $48 a month out of pocket for the four drugs she takes. But for about a year, she hasn't been buying test strips needed to check her blood sugar levels because she can't afford them with the $810 disability check she gets each month.
"I've just been making do and praying a lot — hoping it's under control," she said.
But Tanner learned recently through an advocate with the State Health Insurance Assistance Program that because of her low income she's eligible for a subsidy that would cover all or a portion of the premium.
Other reasons that eligible beneficiaries aren't signed up include confusion about the program, not having enough prescriptions to justify the cost, and simply not knowing about the benefit.
But with the open-enrollment season for the Part D program going on through year-end, experts said that those holding out might want to reconsider, especially because they would face a late-enrollment penalty if they chose to enroll later. Seniors, however, need to be careful as they pick a plan because of the range of premiums, co-pays, and deductibles and different levels at which drugs are covered, experts said.
This year, Tennessee residents can choose among 49 stand-alone prescription drug plans. And 104 Medicare Advantage health plans are available with premiums varying by plan and co-pays based on the type of drug prescribed. Many also offer free generic medications or low co-pay amounts.
Prices, benefits varyMonthly premiums on the stand-alone plans range from $17.60 for coverage from Coventry Health Care to $100.70 for a premier plan from Aetna Medicare, according to the Centers for Medicare and Medicaid Services. But just because a plan has lower premiums doesn't mean that it's a better alternative. The Aetna Medicare plan, for example, covers many generic drugs during a gap in coverage that enrollees face after their drug costs exceed a certain amount but before they are eligible for so-called catastrophic coverage. By contrast, those enrolled in Coventry's plan would be responsible for 100 percent of their prescription drug charges during that period known as the "doughnut hole."
Also, because beneficiaries' overall costs are determined in part by the number and types of drugs that they're using, they could end up paying more out of pocket on a plan with a low monthly premium. "There's some homework to do, but as a general rule enrolling in Part D (the Medicare drug benefit) is a great value for the vast majority of Medicare beneficiaries," said John Gorman, chief executive of Gorman Health Group, a Washington-based Medi care managed-care consulting firm.
Exceptions include beneficiaries who remain on employer-sponsored plans with better prescription drug benefits than offered under Medicare's drug benefit or military retirees with drug coverage through the U.S. Department of Defense's TRICARE insurance program, he said.
"It's drug insurance, not just a drug benefit," Gorman added. "You could be in perfect health this month and next month you could be walking down the golf course and have a heart attack and find yourself on five new medications that would be covered by Medicare."
The late-enrollment penalty is another reason to sign up early, experts said.
Eligible beneficiaries who didn't enroll when the drug benefit began or who delayed signing up since becoming eligible must pay a percent of the average national premium for each month they delay enrollment. Dating to 36 months ago, when the drug benefit was launched, that now adds up to an additional $9.72 to $9.79 per month.
Penalty waivedFortunately for Tanner, 65, the late-enrollment penalty was eliminated earlier this year for low-income seniors. She's probably will qualify for 100 percent of the low-income subsidy and would face a small co-payment, said Rachel Jones, an advocate with the State Health Insurance Assistance Program in Nashville. People with employer-based prescription-drug coverage also can avoid the late penalty as long as they can prove that they didn't enroll earlier because they had another source of drug coverage.
Interest Rate Buy-Down is Major Element of NAR Housing Stimulus Plan
Nashville-based group leads charge to reform health care
Washington Report: Tax Credit For Homebuyers
Rise in insurance costs dwarfs wage increases in Tenn.
