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Byline: Brad A. Greenberg Staff Writer

Marilyn Weiner needs 10 prescription drugs to help manage a long list of ailments: high cholesterol, hyperanxiety, needling pain in her feet and, the most serious, bipolar disorder.

She used to rely on a combination of Medicare and Medi-Cal to pay for the drugs - assistance that allowed the retiree to get by on an annual income of less than $10,000. So she panicked when the Medicare drug plan that took effect Jan. 1 arbitrarily assigned her to a program that wouldn't cover three of the medications, including Neurontin, which stabilizes her mood.

``I'd be climbing the walls'' without the medication, said the 66-year-old Granada Hills resident. ``I'd think I was flying - or I'd want to kill myself.''

Like millions of other senior citizens nationwide, Weiner found herself overwhelmed by the Medicare Part D drug plan, designed to provide cheaper prescriptions to a wider audience of low-income seniors and people with disabilities.

While some seniors have managed to find their way through the bewildering number of alternatives, others have besieged Medicare, pharmacies and insurance companies with questions about which option is best.

``The plan is fraught with confusion,'' said Sandy Risdon, manager of the health insurance counseling and advocacy program at the Medicare-funded Center for Health Care Rights in Los Angeles. ``People are falling through the cracks.''

Verna Ahls, 78, started planning last fall for the switch, gathering information and researching which of the 47 health plans in California would suit her best.

The Canoga Park woman chose Humana Complete, believing her co-payments would be $30. But Costco charged $60 for an antibiotic and $53 for Celebrex because the co-payments vary by pharmacy, a fact lost on many seniors.

``I don't know where to start now,'' said Ahls, one of about 595,000 seniors who became Humana subscribers at the beginning of the year. ``I've tried to call Humana many times. They put me on hold. They say, 'We're too busy. It'll be about a 20-minute wait.' I waited 50 minutes and then it got cut off. I've tried many times since. I cannot get through to anybody.''

Humana spokesman Dick Brown conceded there have been problems in implementing the program.

``We are dealing with them as quickly as we can,'' he said.

Part D also has been causing headaches for pharmacists, who are awaiting reimbursement from the federal government even as they spend hours on the phone with frustrated patients and insurance companies.

``We're filling the prescriptions right now, but we're not getting paid,'' said Albert Daher, a pharmacist and owner of Jay Scott Drugs in Burbank.

The problems are significant enough that California is among nearly a dozen states that have created emergency plans to help residents get the medication they need.

Gov. Arnold Schwarzenegger announced Thursday the state would pay for ``life-saving medications (seniors) are in danger of losing because of significant problems with the new federal Medicare prescription drug program.''

``The governor has saved thousands of lives today'' was the response from the California Medical Association.

Medicare reform was one of the cornerstones of President George W. Bush's domestic agenda. Initially estimated to cost $400 billion over 10 years, the Bush administration now anticipates it will cost $724 billion over that period.

``Who is it serving? The insurance industry and pharmaceutical companies,'' said Nan Brasmer, president of the California Alliance for Retired Americans.

Medicare and health insurers maintain that the majority of seniors soon will be happy with the changes.

``Despite the growing pains, there are millions of seniors across the country that are seeing savings they've never seen before and have access to drugs they didn't have before,'' said Mohit Ghose, spokesman for America's Health Insurance Plans.

A survey commissioned by the industry lobbying group last month found that most seniors thought evaluating the various drug plans was worth their time and most would recommend others sign up for the switch.

The average patient will save about 50 percent, said John Cheevers, a Medicare spokesman. Already, he said, Part D has enrolled a million people nationwide whose prescription coverage was minimal or nonexistent.

Costs vary among plans, and it's been no easy task for seniors trying to select which is best for them. The sheer number of plans - each covering different drugs and having different co-pays - creates countless variables.

On a standard plan, a patient who does not qualify for additional assistance pays an average premium of $32 per month. There is also a $250 deductible. After that, Medicare pays 75 percent of drug costs until the patient hits the $2,250 mark.

This is where seniors enter the so-called ``doughnut hole.'' The patient pays all drug costs until they reach $5,100 in annual drug expenses. After that, Medicare covers 95 percent.

If a Medicare patient previously paid $12,000 for prescriptions, they might pay as little as $4,000 or $5,000 under the new plan.

``This new deal stinks,'' said Rose McAleer, a 73-year-old North Hills woman staying with her HMO. ``You've got to pay $250 and then you might get something? To hell with that.''

Only seniors who receive Medicare and Medicaid (or Medi-Cal in California) are required to get prescription drugs through Part D. This category includes about 1 million of the 4.2 million Californians on Medicare and about 6 million people nationwide.

Enrollment in Part D opened Nov. 15. People only on Medicare have until May 15 to do so without paying penalties. Those on Medicare and Medicaid, known as ``dual-eligibles,'' had until Dec. 31 to choose a health plan before automatically being enrolled.

In California, ``virtually all were auto-enrolled,'' Cheevers said.

This contributed to confusion in pharmacies and created a bottleneck at Medicare and insurance call centers. Medicare boosted its call center capabilities thirtyfold.

Senior advocates say the government was shortsighted in how it implemented Part D. For example: Seniors were encouraged to surf for answers.

``Everything is developed on the Internet. Sixty to 70 percent of the seniors I talk to don't have access to a computer or don't know how to use a computer,'' said Evelio Franco, who facilitates Medicare enrollments at ONEgeneration in Van Nuys.

Weiner was automatically assigned to Health Net. After a week of uncertainty, she was told Wednesday afternoon that a doctor's note sent to the insurer will enable her to get the drugs with a $3 co-pay each. She previously paid nothing because her annual income is less than $10,000.

Patricia Verdugo is waiting. A 43-year-old former psychiatrist on Medicare and Medi-Cal, she switched to Humana before Jan. 1 because she was told they covered her prescriptions.

``But they didn't know the difference between oral and IV,'' said Verdugo, who is continually connected to an intravenous tube because her stomach cannot absorb drugs.

She has prescriptions to fight chronic urinary and kidney infections and a back disease - osteomyelitis - that causes her forehead to parallel the floor when she stands.

She has enough medication to cover her until mid-week.

``This Medicare D is the worst thing that could happen to someone like me,'' she said. ``What are they doing? Are they leaving us to crawl into a hole and die?''

Brad A. Greenberg, (818) 713-3634



2 photos, box


(1 -- 2) Marilyn Weiner of Granada Hills, left, previously paid nothing for her 10 prescriptions. At right, Eleonore Modie consults with pharmacist Albert Daher.

John Lazar/Staff Photographer


Medicare nightmare

SOURCE: Daily News research by Brad Greenberg

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Publication:Daily News (Los Angeles, CA)
Date:Jan 16, 2006

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