Medicare#039;s drug coverage has me dazed, confused

Published 12:00 am Friday, November 18, 2005

Sometimes I think the Bush administration does everything to prove that government doesn't work. I called the Social Security Administration office last week to find out about this new program.

The hypothetical conversation may have gone something like this.

&#8220Ma'am can you explain if this new program will help me?” I asked.

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&#8220Absolutely, sir. How much do you currently pay a year in prescriptions?” the woman responded.

&#8220Humm. Not exactly sure, but, well maybe about $1,200 out of pocket. And I think the company I work for pays 60 percent, so I suppose my total cost is $3,000,” I said.

&#8220Well, that helps sir. First, there is a $250 individual deductible,” she said.

&#8220OK, so I pay the first $250, which would mean you pay $2,750?” I asked.

&#8220Oh no sir, it doesn't work that way. After you pay the first $250 you pay 25 percent of each prescription,” she told me.

&#8220OK, so if the total is $2,750, I pay about $587 more. Then you guys pay the rest?” I asked.

&#8220No, sir, there is also a $32 a month membership fee in the program.

&#8220Ouch! That's $384 a year.

OK, then you pay the rest?” I asked.

&#8220Well sir, not exactly. You see, your coverage is only good up to $2,250 a year. So you would pay the $750 after $2,250 until your total of $3,000.”

&#8220Wow, this is getting confusing,” I said.

&#8220Not at all sir, it is perfectly clear,” the woman said politely.

&#8220Hummm. OK, so I pay $250 up front. Then I pay a $32 a month premium, or $384 a year. Then, if I have it right, I pay 25 percent

of my prescription costs between $251 and $2,250 per year, or $500. After that I pay everything over $2,250, which is $750. Is that it?”

&#8220Why yes sir, that is correct,” she said.

&#8220So, I pay $1,884 and you pay $1,116. That means I pay 63 percent of my costs to be on your plan and you pay 37 percent, right?”

&#8220Yes, sir.”

&#8220OK, so that's it, I have it all, correct?”

&#8220Not exactly sir. You must select a plan from those offered in your state. No one plan offers all drugs, so be sure to select one that offers many of your prescriptions.”

&#8220Whoa! What if no plan pays for all of my prescriptions?”

&#8220Well sir, that is certainly possible. You would pick the best match, then pay the entire costs of any prescription outside of the plan you choose.”

&#8220But if I had to choose between plans that pay either for my Lipitor or my Plavix the one not included would cost me almost $300 a month. That would be $3,600 a year. Are you kidding? I mean, that is really possible?”

&#8220Sir, the plans are created by private companies,” she said. &#8220We have no say over what drugs are included in each plan.”

&#8220OK, well, do I have it all now?” I asked.

&#8220Just about sir. One last thing. There is not coverage between $2,250 and a total out of pocket of $3,600. Once you have paid $3,600 in any year of your own money, then Medicare will pay 95 percent of your costs for the balance of the year.”

&#8220Great. So I pay $1,884 then have to pay for Plavix which costs $3,000. I pay $3,600, then you pay 95 percent of $1,284, or $1,224, and I pay $3,600 plus $64 for a total of $3,664. So, the final deal is I pay $3,664 and Medicare pays $2,340. I pay 61 percent and you pay 39 percent. So that's it, right?”

&#8220One last detail, sir. Should you not enroll by June 2006 your premium percentage rises 1 percent for each month you delay after June.”

&#8220Thanks for your help. I can't imagine why people don't understand this stuff. By the way, will you use this program?”

&#8220No, sir, I buy my prescriptions from Canada. Don't tell anyone.”

Dr. Jim Crawford is an administrator at Ohio University Southern. He can be reached at