Chairman of the Pharmacists Society of the State of New York
For most of us, a “donut hole” is a something sold by the box at Dunkin' Donuts.
This year these words have taken on a completely new meaning thanks to the new program for our senior citizens called Medicare Part D Prescription Program. In January of this year, we were all introduced to the plan, as seniors without drug coverage were forced to join the program. This was supposed to be an enhancement of the current Medicare benefit provided to senior citizens.
The program has a $250.00 deductible, after which Medicare pays for seventy-five percent of drug costs up to $2,250.00. From $2,250.00 to $5,100.00, the patient pays the full cost of medications - this is what is now referred to as the “donut-hole.” After reaching $5,100.00 in drug costs, Medicare will pay for 95 percent of all drug costs for the rest of the calendar year. This means that the Medicare recipient will have to spend $3,600.00 out of pocket just to reach the point of 95 percent coverage by Medicare.
The Kaiser Foundation estimates that the average senior citizen on three medications will only spend $3,426.00 a year for their medications. The Kaiser Foundation also estimates that approximately 38 percent of those enrolled in the Part D Program will fall into this category. Most of these senior citizens, since they fall into the “donut-hole,” will pay for most of the cost of their medications. It is estimated the average Part D Prescription enrollee will spend $400.00 in the second quarter of the year and that amount will triple to an out-of-pocket expense in the third and fourth quarter of $1,390.00.
The Medicare Part D Plan was ill-conceived and poorly thought out. The program does not benefit Medicare recipients as much as it allows the insurance industry and pharmaceutical manufacturers to increase their profits. Most Americans will have to spend their way through the “donut hole.” However, New York State has a prescription program called EPIC for low and moderate income senior citizens that will help take a bite out of the ”donut hole.” It is a program that the state has had in place for many years to help defray the cost of medication to senior citizens.
EPIC (Elderly Pharmaceutical Insurance Coverage) covers seniors 65 years old or older with an annual income of no more than $35,000.00 if single and up to $50,000.00 if married. The program can be used in conjunction with the Part D Prescription program or it can be used alone. The Federal Government Centers for Medicaid and Medicare Services (CMS) considers it a “creditable” plan, meaning it is considered to be as good as or better than Part D. The plan works on a deductible or a quarterly fee schedule and a minimal co-payment. All New York seniors within the income guidelines are eligible. The toll-free help line for EPIC is 1-800-332-3742.
Congress needs to make this program a filled donut with a benefit that helps the senior citizen and not the insurance industry or pharmaceutical manufacturers. There needs to be a drug benefit that can help cut costs for those who need it most.
Bill Scheer R.Ph. is Chairman of the Pharmacists Society of the State of New York