Is my drug going to be covered?
That's a question at the top of the list for most senior citizens as they weigh whether to sign up for the new Medicare prescription drug benefit during the enrollment period that begins Tuesday.
And the answer, most often, will be yes.
Despite political spin from critics of the Medicare drug benefit, generally 80 percent to 100 percent of the nation's most-used prescription drugs will be on participating health plans' preferred drug lists, known as formularies.
Almost all lists cover the nation's most popular drugs, ranging from blockbuster brand names like cholesterol-lowering drugs Lipitor and Zocor to generic prescription ibuprofen.
Not every plan, though, will cover drugs like folic acid, a popular nutritional supplement that health plans say can be bought easily over the counter, or the controversial anti-anxiety drug Xanax.
The pain-killer Celebrex also has been left off some health plan lists because it has been linked to increased risks of heart attacks and strokes, largely because it is in the same class as two drugs already pulled from the market: Vioxx and Bextra.
But it is up to the private health plans that contract with the Medicare program to decide what drugs will be on the preferred drug list. Co-payments vary from plan to plan.
In Illinois, 16 companies offering more than 40 stand-alone prescription drug plans are covering between 74 and 100 of the 100 most-prescribed drugs.
The top 100 drugs are those that were most commonly prescribed to the more than 6 million Medicare beneficiaries who signed up for the program's drug discount cards last year and this year.
"Unless they have some rare disease, their drugs should be on the list," said Joyce Lane, vice president of investor relations for Torchmark Corp, parent of United American Insurance Co., which is selling stand-alone Medicare drug plans in every state except Alaska and Hawaii.
Medicare drug discount cards have been used since June 2004 as a bridge to the broader coverage that begins Jan. 1. The discount program will end Dec. 31.
Although plans will cover most drugs, seniors still should check with their plans to confirm that their drugs are on the list. They should also check to see if the pharmacy they use is in their plan's network.
Some health plans have arrangements with certain pharmacy chains, which could result in seniors getting better deals on their prescriptions.
Seniors who do not like their plan because the cost of a drug is high or a certain prescription will not be covered likely will have to wait until the next open-enrollment period before they can switch to another plan. This year's enrollment period runs from Tuesday through May 15. But the sign-up period for following years generally will begin Nov. 15 and run through Dec. 31, Medicare officials said.
It is possible, too, that a health plan might stop covering a drug. If it did so, the insurer would have to notify a Medicare drug-plan member 60 days in advance of such a decision.
So which drugs are not on the list? For the most part, health plans say drugs not on their lists are either seldom used by beneficiaries or are similar to drugs already covered. Some drugs don't make the list because there are over-the-counter versions seniors can get cheaper elsewhere.
PacifiCare Health Systems Inc., for example, has between 77 and 86 of the top 100 drugs on its formularies and does not cover all 100 for a variety of reasons.
"If there is a brand-name drug, and there is a similar generic equivalent, most likely we are going to have the person try the generic," said Cheryl Randolph, spokeswoman for PacifiCare, which is offering three stand-alone plans in Illinois.
"In most cases, the generic is the same equivalent drug," Randolph said. "The consumer and senior is going to pay a lower out-of-pocket cost for the co-pay of the generic."
Some plans also are keeping drugs off of their formularies for safety reasons. PacifiCare, for example, is among several health plans keeping the painkiller Celebrex off of their formularies.
Celebrex is a so-called Cox-2 inhibitor, a class of drugs that also includes controversial painkillers Vioxx and Bextra.
Although Celebrex has not been as widely criticized as Vioxx and Bextra, some researchers believe the cardiovascular risks are part of a class effect and, therefore, should be avoided, particularly in older patients with increased risks of heart attacks and strokes.
Some health plans are keeping the anti-anxiety drug Xanax off their lists as well, citing studies that show it can fuel a decline in the elderly, particularly those who are weak and in poor health. Even when it is prescribed as a tranquilizer for the elderly, studies have advised low dosages.
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Medicare begins open enrollment Tuesday for its new prescription drug coverage plans. A variety of plans, each with different features, will be offered by private health insurers. Medicare beneficiaries have different prescription drug needs, and the amount they will have to pay will change as an individual's annual costs rise. Here's a guide to how costs will be shared:
1 DEDECTIBLE For first $250 worth of drugs
WHAT BENEFICIARY PAYS: $250
WHAT THE PLAN PAYS: 0
VALUE OF DRUGS RECEIVED: $250
2 INITIAL COVERAGE For next $2,000 worth of drugs
WHAT BENEFICIARY PAYS: 25% co-insurance up to $500
WHAT THE PLAN PAYS: 75% co-insurance up to $1,500
VALUE OF DRUGS RECEIVED: $2,000
3 COVERAGE GAP For next $2,850 worth of drugs
WHAT BENEFICIARY PAYS: Up to $2,850
WHAT THE PLAN PAYS: $0
VALUE OF DRUGS RECEIVED: $2,850
4 ONCE BENEFICICIARY PAYS $3,600
WHAT BENEFICIARY PAYS: Whichever costs more 5% of drug cost OR $2 for generics/$5 for brand names
WHAT THE PLAN PAYS: 95%
VALUE WHAT THE PLAN PAYS
VALUE OF DRUGS RECEIVED: Unlimited to end of calendar year.
Source: Department of Health and Human Services
Chicago Tribune/Van Tsui and Keith Claxton
- See microfilm for complete graphic.
Private managed-care companies for years have offered plans to help Medicare recipients extend their benefits and cover some medications. Some may offer more savings than the new Medicare drug benefit.
Two state pharmaceutical-assistance programs, Senior Care and Circuit Breaker, are being changed and merged into a new program called Illinois Cares Rx to coordinate with the Medicare drug plan.
Find stories on the Medicare drug benefit online at chicagotribune.com/medicaredrugs.
READER CONNECTION Would you like to learn more about Medicare prescription drug coverage, compare plans or find out if a specific drug is covered? Go to the Medicare Web site at www.medicare.gov.
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