URBANA – For Dorothy Berger, the gap in her new Medicare drug plan arrived way too fast.
Less than five months after her new Medicare prescription drug coverage took effect Jan. 1, she went to her pharmacy to pick up her monthly pain patch and got a big surprise.
"I had my $10 out to pay $8 for the patch," she recalled. "The pharmacist said no, it's $489 and some change."
Berger, 82, of Urbana, has arrived at the dreaded gap in the government's new prescription drug plan for the elderly, Medicare Part D: The so-called "doughnut hole."
The way many of the Medicare drug plans are structured, beneficiaries pay the first $250 of their costs, and then make copayments on the next $2,000 worth of drugs.
After that, the doughnut hole kicks in. There's no coverage between $2,251 and $5,100.
Coverage doesn't pick up again until a beneficiary reaches the greatest of these two costs: either $5,100 in total pharmacy costs or $3,600 out-of-pocket costs.
Berger said she worried about that gap when she enrolled in Medicare Part D through one of the many plans available in Illinois, the one offered by Urbana-based Health Alliance Medical Plans.
She worried because she needs a lot of prescriptions every month. There's the pain patch and another medicine for her spinal stenosis. She also has to buy insulin for her diabetes and blood pressure medication, she said.
Berger said she doesn't know yet what the other medicines are going to cost her at full price, but she's awfully worried about the pain patch now that she knows how much it costs. She ended up leaving the drugstore without it – at least this time.
"I felt really upset. I didn't now what I was going to do," she said.
Medicare spokesman Bob Herskovitz said the Illinois Cares Rx program can help income-eligible seniors get through the coverage gap. And there are some plans available in the state that don't have a coverage gap, though the premiums might be higher.
"We do have several plans that were designed for this situation," he added.
Jana Perry, director of Medicare and Individual Services for Health Alliance Medical Plans, said Berger is one of the first to land in the coverage gap because her medications are so expensive.
"Unfortunately, that patch is quite expensive. Up until now, she's paid $8. The health plan paid the other $400," she added.
Health Alliance is trying to help its members in that situation by putting together a list of pharmaceutical companies that may help cover the cost during the coverage gap period, Perry said.
Katie Coombes, Medicare 100 Plus coordinator for Champaign County Health Care Consumers, said her organization sees the coverage gap as a big flaw in the Medicare Part D program. Coverage should be more consistent, she said.
As it stands now, "eventually you make it to the catastrophic coverage, but you've just got to get through it," she said.
Berger doesn't like it much.
"This system is terrible and that's all there is to it," she said. "Whoever dreamt this up must have had a rock between their ears."