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Relief available for seniors who see gap in prescription drug coverage

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A St. Lawrence County Office of the Aging employee who is concerned that seniors are not purchasing medications due to a gap in their Medicare Part D prescription coverage is spreading the word out about a supplemental state prescription drug copay program.

In 2014, for seniors spending up to $2,850 on covered drugs — the combined amount plus the patient’s deductible — there is a “doughnut hole,” or gap, in their prescription coverage where they must pay the full cost of drugs before the plan’s cap kicks in.

Nancy Green, a health and human services coordinator and a state health insurance assistance program counselor, said Wednesday some seniors are forgoing their medication because they can’t afford their prescription copays, which, in extreme cases, have reached over $1,400 a month, during those coverage gaps.

Ms. Green, who works out of the St. Lawrence County Office for the Aging office in Canton, helps seniors navigate the Medicare system.

“There are a lot of seniors who just don’t know what their options are or that these programs are out there and many of them meet the requirements,” Ms. Green said. “The first thing I do when I meet a senior is to screen them for eligibility for any of the programs they might be eligible for.”

Not everyone will enter the coverage gap, Ms. Green said. The gap begins after a patient and patient drug plan have spent a certain amount for covered drugs.

Seniors who regularly take expensive medications for cholesterol and diabetes are often more likely to see their prescription coverage run out early because those medications are especially expensive, Mss. Green said.

Once seniors reach the coverage gap for 2014, they will pay 47.5 percent of the plan’s cost for covered brand-name prescription drugs.

A patient’s yearly deductible, coinsurance, and copayments all count toward the coverage cap, according to Medicare.Org.

There are some seniors whose medications are so cost prohibitive that they reach the “doughnut hole” as soon as January, Ms. Green said.

“It’s heartbreaking,” Ms. Green said Wednesday. “There are a lot of seniors falling through the cracks. For many seniors, they hit the ‘doughnut hole’ sometime between October and December — a time in the year when they cannot afford the high cost of heating their homes. It boils down to, ‘Okay, do I heat my home or do I pay for my medications?’”

The stakes are high, Ms. Green said.

“Depending on what they are suffering from, their prognosis will not be good,” Ms. Green said. “A lot of these medications are keeping our seniors alive.”

But there is relief for some Medicare subscribers, Ms. Green said. Under the New York Elderly Pharmaceutical Insurance Coverage program, or EPIC, administered by the Department of Health, seniors who meet eligibility standards can receive help with co-payments for Medicare Part D-covered prescription drugs after the Part D deductible is met.

Ms. Green said many seniors do not know that the program is available.

Ogdensburg resident Sandra Y. Sanders said she was beside herself when she learned that she would have to pay over $500 for her monthly medications. She regularly relies on pricey medications, such as NovoLog and Levemir, to manage her diabetes.

“I was in tears,” she said. “I didn’t know what to do.”

With the help of an Ogdensburg pharmacist, Ms. Green joined EPIC on her 65th birthday in May.

“Every senior should know about this,” she said. “I had no idea that I even qualified. I thought I had to be 72 or older.”

To join EPIC, the person must be a state resident, 65 or older with an annual income up to $35,000 if single or $50,000 if married. Seniors with a Medicaid spend down not receiving full Medicaid benefits are also eligible. Members pay an annual fee to EPIC based on their income.

Copayments for prescriptions costing $55.01 or over, range from $3 to $20 based on the cost of the drug. Those with Full Extra Help from Medicare have their fee waived.

Under the plan, EPIC also pays the Medicare Part D plan premiums, up to the amount of a basic plan for members with annual income below $23,000 if single and $29,000 if married.

Under the Affordable Care Act, the gap is shrinking each year and is set to reach 25 percent in 2020.

“But that is not a consultation to many of my clients who are struggling now,” Ms. Green said. “We still have to turn some people away who are just over the eligibility requirements who could benefit from the program.”

To fill out an application for EPIC, a list of other supplemental insurance options or basic insurance options, seniors should contact Ms. Green at the Office for the Aging at 386-4730.

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