Health care reform bill tries to fill part of 'doughnut hole'

2010-04-25T22:56:00Z Health care reform bill tries to fill part of 'doughnut hole'By MIKE DENNISON Missoulian State Bureau

HELENA - For the 28,000 Montana senior citizens who hit the "doughnut hole" in Medicare prescription drug coverage, the health reform bill passed by Congress provides some minimal help this year: A $250 check to fill a hole as deep as $3,600.

It may not be much, but it's a start, advocates for the elderly say, for the bills take further steps next year and down the road to reduce the out-of-pocket cost for some seniors who have Medicare coverage for prescription drugs.

Yet the reform measures may be more notable for what they don't do regarding prescription drug prices. Most advocates say the bills didn't do enough to lower drugs' cost, such as allowing the federal government to negotiate directly with manufacturers to lower prices for drugs covered by Medicare.

"We believe ... we should be taking further steps to lower the cost of prescription drugs, such as safe, legal importation, removing the brand-name companies' monopoly on biologic drugs and allowing Medicare to negotiate for lower drug prices," said Stacia Dahl, spokeswoman for AARP-Montana.

AARP is the consumer group whose membership is citizens 50 years or older, including 164,000 in Montana.

Medicare is the government health insurance program that covers about 45 million elderly Americans, including 160,000 Montanans.

The so-called doughnut hole is a gap in Medicare prescription drug coverage that kicks in once you've purchased $2,830 worth of prescription drugs for the year.

Up to that point, Medicare covers about $1,900, or two-thirds, of the cost of the drugs. But for the next $3,610 worth of drugs you buy, there is no coverage at all. You pay full price until you hit that ceiling, after which Medicare covers 95 percent of the cost.

Tobey Schule, the owner of Syke's Pharmacy in Kalispell, said people with heart problems or diabetes can hit the coverage cap pretty easily.

"It can be pretty devastating for them," he said. "We have a lot of low-income customers who use our pharmacy, so we see it more than a lot of pharmacies. ...

"Some patients, even if they hit the doughnut hole, their income is such that they should (be able to pay). But for others, it's deciding whether they take their drugs or eat."

This year, Medicare beneficiaries who hit the doughnut hole will get a one-time check from the feds for $250. Beginning next January, they'll also get a 50 percent discount on brand-name drugs.

Then, over the next nine years, a series of phased-in discounts and benefits will lead to elimination of the doughnut hole, leaving those covered by Medicare with a 25 percent co-pay for all drugs up to the point where they hit the "catastrophic coverage," when Medicare pays

95 percent.

Dahl said AARP, which lobbied hard to address the doughnut hole problem, is pleased that the bills tackled the issue, but acknowledges that more needs to be done.

"Now that health-insurance reform is enacted, AARP will continue our fight to lower prescription drug costs for seniors and all Americans," she said last week.

Missoulian State Bureau reporter Mike Dennison can be reached at 1-800-525-4920 or at


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