1. Potera, Carol

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While some Americans have found Medicare Part D to be a boon, others have found that signing up for Medicare's new stand-alone drug plans is a herculean task, that drugs are sometimes more expensive, and that the plans vary significantly in coverage (see the recent analysis by the Henry J. Kaiser Family Foundation, In seeking to illuminate nurses' experiences with Medicare Part D, AJN talked recently with three nurses, all of whom encountered difficulties in gaining the information needed to accurately assess the pros and cons of signing up.


This aspect of the system has led to some embarrassing moments at the pharmacy. 'They tell me the price and I have to say, "Sorry, I can't afford that,"' says Franklin.


Hidden costs.

In Pensacola, Florida, Melissa Franklin, RN, made an early choice to enroll in Humana, one of Medicare's drug plans; coverage began January 1, 2006. A nurse for 30 years, she practiced critical care and emergency nursing before becoming partially disabled by Moersch-Woltmann syndrome, commonly known as "stiff-person syndrome." Management of this autoimmune neuromuscular disorder requires several medications, including muscle relaxants, analgesics, anticonvulsants, and antidepressants. Because Franklin receives disability benefits through the U.S. Social Security Administration, she had been able to obtain several drugs from pharmaceutical companies through a pharmaceutical assistance program coordinated by her clinic. In February 2006, Franklin learned that the drug companies had refused to provide assistance to those with Medicare Part D. "Even though I couldn't afford the drugs," she says, "I had to get prescriptions through Medicare Part D."


This meant cutting back on the brand-name drug Lamictal (lamotrigine), an anticonvulsant that relieves her neurologic symptoms and that adds $100 or more to her monthly pharmacy bill. "That may not sound like a lot of money to some, but it's a lot to me," Franklin says. Surprisingly, the generic version of the drug costs twice as much as Lamictal under the Humana plan. When she tries to fill half a prescription because she cannot afford a full one, some pharmacies refuse to comply and others charge as much as they would for a full one.


Franklin has also discovered that under the Humana plan, pharmacists are unable to tell her how much a prescription will cost until the pharmacy has filled the prescription, despite the fact that Medicare Part D allows prescription drug plans to change copayment amounts (or to simply decide they will no longer cover a certain drug at all). This aspect of the system has led to some embarrassing moments at the pharmacy. "They tell me the price and I have to say, 'Sorry, I can't afford that,'" says Franklin.


She thought that she was doing the right thing by selecting a plan early. Now she realizes that if she had waited until the May 15 deadline (enrolling after this date means the premium rises by 1% each month), she could have continued, at least for a time, to receive some medications through the pharmaceutical assistance program.


Better off without it?

When AJN talked with Marguerite Guin of Gainesville, Florida, a month or so before the May 15 deadline for signing up, she still was undecided. The 85-year-old retired nursing instructor was uncertain whether enrolling was her best option, considering the monthly fees, deductibles, and copayments. Guin takes just three medications to control blood pressure and cholesterol levels and a tremor caused by a recent car accident. Would she be better off buying the drugs without enrolling in Medicare Part D? "I've read all these manuals, and the whole thing is super confusing," says Guin.


As an alternative to Medicare Part D, Guin is considering private discount programs, such as Rx Outreach, recommended by friends. This private plan does not charge an enrollment fee and is open to people whose income is below a certain level ($24,500 for a single person), and Guin's friends report being able to purchase some drugs at half the price they have paid elsewhere. Although Medicare advertisements advise enrollees to talk to their pharmacists about the Medicare plan, Guin says "I haven't found a pharmacist yet who knows much." Instead, pharmacists tell her to call Medicare or visit the Medicare Web site. "There's too much information to grasp, and I'm confused by the literature," says Guin.


Deciphering the options.

Equally perplexed is Guin's daughter, Peggy Guin, PhD, ARNP, a clinical nurse specialist in medical-surgical nursing with Shands HealthCare at the University of Florida, Gainesville. "I've looked at all the literature and tried to call Medicare and gotten lost in phone trees," she says. She wonders why Medicare did not, for instance, devise a Web site that would allow a person to plug in the drugs she takes and list the plans suitable to her. "From what I've read, you still pay a Medicare premium and copayment. So if you take just a few drugs, you could pay more money out of pocket than if you buy the drugs on your own," she says. "It's extremely complicated to figure out, a huge bureaucratic mess."