Costly drugs in 'specialty tier'

KNIGHT RIDDER NEWSPAPERS
Q. I have rheumatoid arthritis and was careful to pick a Medicare drug plan that covered the one expensive medication that I need for this condition. Now I find that I am paying $140 each month for this one drug, which is not much help! I am told that there are other Medicare drug plans that charge a much lower fee for my medication. What can I do? -- Caroline
A. There is little you can do to lower your drug costs before 2007 unless your physician recommends a less-expensive drug that would work equally well. Under the Medicare drug benefit, you cannot switch plans until the 2007 enrollment period, which runs between Nov. 15 and Dec. 31, 2006.
If you decide to look for a new Medicare drug plan for next year, check to be sure the medications you take are covered and then find out how much you will be required to pay each time you fill a prescription. Many plans place the most expensive drugs, like those used to manage rheumatoid arthritis, on a "specialty tier." When they do, enrollees tend to pay substantially more than they would if the drug were covered under standard cost-sharing tiers. If you are now paying $140/month, your medication is almost certainly on the plan's specialty tier.
Unfortunately, the amount you are paying for your medication will probably increase later in the year if you are enrolled in a plan with a coverage gap (sometimes called the "donut hole"). Most of the Medicare drug plans today have such a gap in coverage. After drug expenses reach a certain point, the plan stops paying, and the enrollee pays the full amount for their medications. If you reach this point, the amount you pay for a given drug on the specialty tier could triple or even quadruple until you qualify for the catastrophic benefit.
This column was prepared by the Kaiser Family Foundation, an independent, nonprofit private foundation based in Menlo Park, Calif., not affiliated with the Kaiser Permanente health plan. Send questions about the new Medicare drug benefit to Medicare Q & amp; A, The Kaiser Family Foundation, 1330 G St., N.W., Washington, D.C. 20005 or MedicareQ@kff.org.