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It's enough to make them sick On Jan. 1, the new federal prescription-drug benefit took effect. Untangling the complexities of Medicare Part D has been frustrating and time-consuming for many beneficiaries, and some have struggled to get the plan to cover crucial medications. Here are four people's stories. March 26, 2006 Bait and switch Jerry Warren AGE: 70 HOME: Salem, N.H. MEDICAL CONDITION: Had a quadruple cardiac bypass operation in 1994 NUMBER OF PRESCRIPTION DRUGS: 11 COVERAGE OVERVIEW: One of his cardiac drugs isn't covered because Medicare classi? es it as a prescription vitamin. Jerry: I had a quadruple bypass in November 1994. I never had a heart attack -- my problem was angina, and my symptoms were a feeling of weakness in my left forearm and I get slight nausea. One of my medications is Niaspan. It's an extended-release form of niacin, and it helps reduce triglycerides and the bad cholesterol. Donna: It keeps you from having a heart attack. Jerry: I had been getting prescription coverage from Blue Cross Medigap Plan J. I could have stayed on it, but it's not considered equivalent to Part D coverage by Medicare. That could have left me vulnerable to paying penalties if I switched later to a Part D plan. Donna: We searched on the Medicare website to find a drug plan that would cover all of Jerry's medication. We joined AARP Rx, the plan run by United Healthcare. When we signed up on Dec. 6, Niaspan was on the formulary. We even called up and confirmed with an actual human being at AARP Rx that all of Jerry's drugs were covered. The first clue we had that Niaspan was not covered was when the pharmacy called. Jerry: In mid-January I dropped off a prescription and got a call two or three hours later. They said Niaspan wasn't covered and it would cost me $174 a month. Donna: I got on the phone to United Healthcare and he said he received notification that Niaspan had been removed from the formulary on Jan. 6. Medicare made the decision that it was considered a vitamin, not a drug. Jerry: You have no guarantee that your drugs are going to remain on the plan, and you're only allowed to change your plan once a year. We have shelter, we have food, and the extra expense for this medication isn't going to take that away from us. But what happened is so inherently wrong. Donna: Do you know what this is? It's a bait and switch. Left adrift in the system Terrie A. Slater AGE: 45 HOME: Salisbury MEDICAL CONDITION: Disabled since brain tumor surgery in 1999 NUMBER OF PRESCRIPTION DRUGS: 8 COVERAGE OVERVIEW: Automatically shifted from Medicaid to Medicare; having difficulty receiving coverage for all medications Before I was diagnosed with my brain tumor in July 1999 I didn't take any medications, aside from birth control pills. Now I have a bowl full of meds. Until January, I was getting my prescriptions from MassHealth, and I never had a problem. I would pay a $1 or a $3 copay. When Medicare Part D came, I just assumed I didn't need D -- I had MassHealth. They didn't make it clear that I had to enroll in a plan. I never got any literature. They should be able to put it in terms I can understand. Now I'm not sure who covers my prescriptions. I bring a prescription to the pharmacist, and I pray they cover it. In January, I ran out of my seizure medication. I went without it for a day. I was starting to get throat seizures -- contractions of the throat that are a precursor to full-blown seizures. If I have a seizure, I won't be able to drive for six months. Now I'm getting by on samples from my primary care physician. She gives me samples of my antidepressant, Lexapro. It isn't covered under Part D. I take it because it works. These are all the same meds I've been on since 1999. I'm trying to keep calm, but I'm in a situation where I have to choose between paying my rent or getting my medication. I get a disability check for $735 a month. The rent here is $355. Last week I had to buy one prescription out of pocket and it cost me $80. If I don't have that drug I won't sleep for three or four days straight. I just got an eviction notice. I'm not really sure what I'll do. I go to food pantries. I'll figure something out. I feel as though I got left out in a dark alley. Nickeled and dimed Johnn O'Sullivan AGE: 67 HOME: Roslindale MEDICAL CONDITION: Effects of a heart attack and arrhythmia NUMBER OF PRESCRIPTION DRUGS: 7 COVERAGE OVERVIEW: Can't coordinate the components of his coverage despite seeking help from various insurers and agencies In November I developed a heart arrhythmia, and then I had a small heart attack. I went to the ER four separate times. Then I chose a Medicare drug plan. Choosing the plan was a major adventure. It took me four solid days. I chose Blue Care, and I still have Massachusetts Prescription Advantage as a secondary payer, which picks up anything that's not covered by Blue Care. But since then, I've kept on having billing problems. I'm unable to get my pharmacy to succeed in billing Prescription Advantage as a secondary insurer. They can bill one or the other, but they can't bill both of them. They've tried. I got billed in February, but for the wrong amount. They billed me $28.64 rather than the $20 premium. I just paid the full amount, and Prescription Advantage is supposed to reimburse me later. I just got an April bill, and it's still $28.64. All this has taken me the equivalent of six days. Every time I made a phone call I was on hold for an hour. It was a tremendous burden. I was involved in actuarial work, so this kind of thing is right up my alley. But it took an effort to understand this new plan. But the design of the benefit is a real disaster. Give people enough choices and it's paralyzing. Then there's the fact the pharmaceutical companies' prices are protected. And when you finally sign up for a plan, it doesn't establish a binding contract on both parties. The drug plans can change the formularies any time they want. I've never seen anything that generates so much red tape. I think about all the people who don't have the mental sharpness to do this. Sometimes I think Medicare Part D is a secret government plan to improve the mental acuity of seniors by giving them all of these word problems and arithmetic. High-stakes runaround Wayne Bailey AGE: 58 HOME: Newton MEDICAL CONDITION: His disabled son, Bryan, 28, suffers from kidney failure and had a liver transplant. NUMBER OF PRESCRIPTION DRUGS: 20 COVERAGE OVERVIEW: Has been unable to get all prescriptions filled since his son was automatically transferred to a Medicare plan Bryan had a liver transplant about 10 years ago that's going south. He also has renal failure, so he's getting dialysis. And he's a diabetic and has high blood pressure. He's on about 20 medications. Bryan has been on MassHealth [the state Medicaid program] for a long time. But when we were put on Medicare in January, Bryan fell through the cracks. We're in this limbo. He's on Medicare Part A and B, which covers hospital care and doctor visits. But why isn't he on Part D? I started calling around. The Social Security people said talk to MassHealth. They have no clue. They said, ''You should have gotten a letter." Nobody's telling me anything about what I'm eligible for. For months, we've been getting by on samples from doctors. That was supposed to go away when we signed up for Part D. What I feared would happen has actually happened: He has no drug coverage. Now I'm kind of panicky. Literally his life can't go on without these people. Today, I tried to figure out which Part D plan to put Bryan on through the user interface on the Medicare plan-finder website. I'm a high-tech entrepreneur, and I really pity people who aren't technically savvy. Making the choice came down to how much these drugs will cost my son. He gets $400 a month in two checks, and we supplement on top of that. For most plans, the deductibles alone are going to kill him. When you call the enrollment people and say he's on SSI, they say they won't deal with SSI, you have to call the SSI folks. Then I call the SSI people, and there's nobody there. I said to one plan, ''If I pick you guys today, when can I get coverage?" Well, the coverage won't start until the next month. I have only 15 days of medication left. I'm looking at the retail cost of these drugs, and we're talking a couple-thousand dollars for just 15 days. If you're not persistent, I don't know how you can get through this. I'm not a stupid person, but this really makes me feel stupid. © Copyright 2006 Globe Newspaper Company. 1 2 3 More: ---------------------------------------------------------------------- To sign-off Parkinsn send a message to: mailto:[log in to unmask] In the body of the message put: signoff parkinsn