By JANE BRODY
Maybe you already signed up for Medicare Part D, the prescription drug benefit plan, and maybe you didn't. Either way, experts who have been monitoring the way the plan operates strongly urge that every Medicare recipient take a second look.
Those already in a plan may want to consider changing plans during the next sign-up period, Wednesday through Dec. 31. Those who are still on the fence about whether to join a plan may want to enroll now, before the penalties for delayed enrollment increase significantly.
Though legislation is pending in Congress to drop the premium penalties, at least for this first year, they are still in place and amount to 1 percent of the average national monthly premium for each month that you didn't sign up.
If you haven't yet signed up and do so in November, you will pay a premium penalty of 7 percent - 1 percent for each month since May. If you wait a year, the premium penalty will be 19 percent, and the average national premium may be higher as well. Furthermore, these penalties are not a one-time matter; they will stay with you as a higher monthly premium for as long as you are in a Part D plan.
People who currently have drug benefits through other insurance plans should not join a Part D plan unless it is much better than their current coverage.
They will not be penalized for joining a Part D plan at a later date unless they lose their current benefit and fail to sign up for a Medicare plan at the next opportunity. Deane Beebe of the Medicare Rights Center, a nonprofit advocacy group in New York, pointed out that people with drug benefits through a non-Medicare plan risked forfeiting their current coverage if they signed up for a Part D plan.
There are two main problems with Medicare Part D:
1) There are far too many choices. California, for example, has 55 stand-alone prescription drug plans statewide, not counting dozens more in individual counties. Each plan has its own premium, its own formulary for the drugs it covers, its own deductible and its own co-payments for individual drugs. A consumer taking half a dozen or more prescription drugs may need a degree in higher math to figure out which plan would provide the most benefits. During this next sign-up period, the Medicare Rights Center will provide free access to its plan finder, at www.medicarerights.org/help.html.
2) It is very difficult to get accurate, unbiased information about individual plans. Part D plan call centers are run by private companies, and a recent study by the Government Accountability Office and advocacy groups found that consumers got correct answers only one-third of the time when they called for information about drug plans. The 1-800-MEDICARE (1-800-633-4227) line does a better job, with two-thirds of its answers correct, the study found.
Though few, if any, consumer groups are happy with the way the Part D plan was constructed and are even less pleased with how it is being administered, they are inclined to recommend - albeit reluctantly - that Medicare recipients who do not have prescription drug coverage through an employer or a private insurer join a plan even if they currently use few if any prescription drugs.
David Lipschutz, a lawyer for California Health Advocates, a nonprofit agency that advises state health insurance and Medicare programs, said even if you do not need it now, "it's probably a good idea to pick up a plan and pay for it as you would any other insurance policy."
The problem is this: Say you currently take no prescription drugs or only one such drug daily, perhaps to lower blood pressure or cholesterol or relieve painful arthritis. With the monthly premium for a Part D plan, the deductible and the co-pay for each prescription, you may reap little or no benefit from being in a plan now, and may even lose money. But what if you are found to have cancer or multiple sclerosis between Jan. 1 and Nov. 15, 2007, the latter being the start of the next sign-up period? And what if the best treatment for your disease is an astronomically expensive drug? Will you be able to afford it?
Of course, the plan you signed up for in 2006 may not cover that drug, in which case you will have to file an appeal for coverage, a process that can take much longer than Part D regulations mandate. The Medicare Rights Center - 1-888-466-9050 - has a cadre of volunteer lawyers who provide free services to consumers having trouble with appeals.
In choosing a plan, start with the Medicare Web site, www.medicare.gov , and click on Medicare Prescription Drug Plan Finder. If necessary, get someone who is computer savvy to help you. When comparing plans, look not only at the premiums, deductibles and co-pays for the drugs you take, but also at the kinds of restrictions that may be placed on your drugs. Do they require prior authorization? Will you have to use "step therapy" - start with a cheaper drug and if that doesn't do the job, will the plan cover a more costly one? Are there quantity limits?
Before signing up, double-check with the plan itself about coverage. "Last year," Beebe said, "there were a lot of mistakes" in the plan finder. She also cautioned against being "sucked in by zero-dollar premiums offered by some managed care plans unless you determine that managed care will work for you."
You may already be in a Part D plan or have prescription drug coverage with your regular medical insurance. Perhaps your current insurer sent you a letter stating that its plan was at least as good as Medicare's and advising you to stick with the insurance you have. In general, that is good advice.
If you have already signed up for a Part D plan, you would be wise to review the coverage you are getting. "You can't assume that a plan that worked well this past year will work well next year," Beebe said. "Plans change, and individuals' needs may change. No one is free from having to go back and look at all the options to see if another Part D plan, or an outside plan, would work better for you."
For example, the plan you signed up for may no longer cover one or more of the drugs you take. When a drug is dropped, the plan is required to provide 60 days' notice or a 60-day supply of the drug, but beyond that it comes out of your pocket.
You have probably also heard of the "doughnut hole" in Part D plans. This is the point at which you and your insurer combined have spent $2,250 on drugs. After that, you have to pay all drug costs until you have personally spent $3,600 this year (the figure could change next year) on drugs covered by the plan.
Perhaps you bought a plan that covered both generic and brand-name drugs in the doughnut hole. But now that plan has changed and it covers only generics, or no drugs at all.
Premiums, too, may have increased from when you signed up. Mergers are taking place among the hundreds of companies that initially provided Part D insurance, and these can result in major changes in coverage.
Jane Brody covers science and biology for The New York Times.
