Juliette Cubanski

From Gladys Kirkpatrick’s point of view, the so-called “doughnut hole” in her prescription drug coverage is gaping.

“I’m not taking this medicine for the fun of it. It’s what I have to have,” said the 81-year-old widow, who lives on $960 a month from Social Security and some savings and last month spent more than $1,000 out of pocket on prescription drugs. “My medicine is costing more than what I draw.”

Stuck in a coverage gap in her Medicare drug plan, Mrs. Kirkpatrick is facing another couple of months without any federal help on her prescription costs. Having reached the $2,510 coverage limit for her Medicare Part D benefits, the Cleveland, Tenn., resident said she has about $1,000 more to pay before catastrophic coverage kicks in. Crossing that money gap is forcing her to scrimp in a number of ways, she said.

“I just do without,” said Mrs. Kirkpatrick, noting that she’s put off refilling a $400 prescription for 90 days of her blood pressure medicine. “The money that I had saved, I’ve been using it to buy medicine.”

The coverage gap for people with the Medicare Part D benefit — known as the “doughnut hole” — can be a significant challenge for millions of elderly and disabled people nationwide who rely on the federal health insurance coverage.

As the benefit was designed by the Medicare Modernization Act of 2003, beneficiaries end up saddled with thousands of dollars in out-of-pocket costs between the time when they’ve reached their initial coverage limit and before Medicare’s catastrophic coverage takes effect.

A recent study estimated that 3.4 million people hit the doughnut hole in 2007 and, to compensate, many of them stopped taking medications to manage chronic conditions such as diabetes.

The study, released in August by the Kaiser Family Foundation, found that 15 percent of Part D enrollees who hit the gap stopped their medications, 5 percent switched to other medications and 1 percent reduced the number of drugs they were taking. The study analyzed retail pharmacy claims data, but it excluded beneficiaries who receive low-income subsidies since they do not face a coverage gap.

“When the drug price goes from $15 and $20 to $100 or even $200, that’s a pretty big sticker shock, so I don’t think it’s really surprising that this is what we’re seeing,” said Juliette Cubanski, one of the study’s researchers and a principal policy analyst with the Kaiser Family Foundation, a nonprofit, private foundation focusing on health care issues.

She noted that 10 percent of Part D enrollees using medications to manage diabetes stopped taking their diabetes medications when they reached the coverage gap in 2007 and did not switch to an alternative.

“That might not sound like a large share, but anyone who is taking medications for diabetes could face some potentially severe health consequences pretty soon after stopping their medications,” she said.

LOCAL ASSISTANCE

Chattanooga resident Gary Law, who was diagnosed with HIV in 1989 and has had acquired immune deficiency syndrome since 1995, ended up in the hospital last month after he hit the doughnut hole in May and no longer could afford the costly medication for his HIV/AIDS.

“My problem was I’m on such a fine line with my budget as it is that to have my co-pay go from $25 on up to $200, it is devastating,” he said. “I don’t have $3,000-plus to pay to get through this gap thing of my own accord. I don’t have that kind of money.”

Mr. Law, who is 53, qualifies for Medicare because he is on Social Security Disability. He spent more than a week in August at Memorial North Park Hospital with pneumonia after having to forgo his HIV/AIDS medication — Atripla — for three months. This month, the nonprofit Chattanooga CARES, which provides financial assistance and medical treatment to people affected by HIV/AIDS, agreed to pay for his Atripla, Mr. Law said.

Locally, as more people enroll in Medicare’s Part D drug benefit, more are confronting the doughnut hole, said Katherlyn Geter, regional coordinator for the Tennessee State Health Insurance Program, which provides objective counseling on Medicare and health insurance issues.

“We’re telling people definitely before they approach the doughnut hole to be prepared and to know there are resources out there,” she said.

Whenever possible, beneficiaries should switch to generic medications, since many plans provide coverage for generics during the doughnut hole, she said.

Beneficiaries in the coverage gap also should contact pharmaceutical companies and patient assistance programs to see if any discounts are available on the drugs they take, she said. The Tennessee State Health Insurance Program, or SHIP, also offers counseling and helps seniors find resources during the coverage gap.

During annual enrollment for the Part D benefit, which this year begins on Nov. 15, beneficiaries must take care to evaluate which insurer’s Part D plan covers most of their prescriptions, she said.

Mrs. Kirkpatrick’s son Bob, who is 58, said he has spent long hours online working to find financial assistance for his mother through the drug companies that manufacture three of her medications.

He said his mother doesn’t know how to use a computer.

“She’s 81 years old, so how in the world are people supposed to survive this mess?” Mr. Kirkpatrick said. “I don’t want sympathy or anything like that. I just don’t want other people to go through the mess I’m going through to try to get her help.”