Next phase brings new worries

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WASHINGTON (AP) – A safeguard designed to ease elderly patients’ transition into the Medicare drug program ended Friday, and that means some people will find they have to pay for their medicine out-of-pocket.

The government had told insurers they must cover a 90-day supply of a drug, even if that drug is not on the plan’s list. Beginning Saturday, they won’t have to.

During the past three months, plans were supposed to be notifying pharmacists and their customers when a prescription was being covered temporarily. However, it’s not clear how often they have done so.

“I haven’t had a single person come to me with notice from a plan warning them that a drug is transitional,” said Buffie Sassvedra, director of New Mexico’s State Health Insurance Program, which advises seniors about insurance coverage.

Some consumer groups worry that many elderly and disabled patients will try to get a prescription refilled, only to find that the drug is no longer covered. Some, they say, may not have the money to pay for their medicine.

Mark McClellan, the Bush administration’s chief Medicare official, told reporters Friday that insurers must cover a drug until they rule on a customer’s appeal, or until that customer switches to a comparable medicine.

McClellan said his agency, the Centers for Medicare and Medicaid Services, was prepared to fine insurers or to halt enrollment in plans that don’t provide those services.

“We will be monitoring closely,” McClellan said.

In a letter to President Bush, 10 Democratic senators said neither CMS nor the insurers have educated seniors about their options April 1. They asked the president to extend the transition period.

“We’re very concerned that many elderly and disabled citizens will not be able to obtain the drugs they desperately need if the transition policy ends,” the senators wrote.

McClellan said he did not know how many people would be affected by a drop in transition coverage. He said he believes that the large majority of beneficiaries have already switched to a new drug or obtained permission from their insurer for continued coverage.

“The plans have notified us that they have been taking the steps that we required to support transitions,” he said. “That doesn’t mean that every single one of them has been done effectively.”

He also stressed that insurers participating in Medicare cover so many drugs that most beneficiaries shouldn’t have anything to worry about.

However, Tim Tucker, a pharmacist from Huntingdon, Tenn., said he sees several patients an hour whose insurance won’t cover a drug now that the transition period has ended. Often, those customers had no idea until he tells them. He said that he saw no warning letters from insurers until just recently.

“I’m real concerned about what’s going to happen on April 1,” he said.

Consumer advocates fear that some elderly and disabled Americans will walk out of pharmacies without their medicine. Then, they will be trapped in red tape trying to appeal to insurers for coverage.

That’s what happened in January for hundreds of thousands of people. About 40 states stepped in on an emergency basis to pay for medicine when beneficiaries did not show up as being enrolled in a plan, or when they were billed excessively. However, all but a handful of states have since discontinued that coverage.

The problems were significant enough that CMS in late January extended the transition period from 30 days to 90 days.

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On the Net:

Medicare: http://www.medicare.gov

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