WASHINGTON — Seniors wanting to avoid the Medicare prescription program's coverage gap have had one clear alternative: Choose a plan that cost more but bridged the break in benefits.
But that option will be more restricted and more expensive next year. The leading national plan that covers brand and generic drugs in the gap -- Humana PDP Complete -- will no longer pay for brand-name prescriptions.
More than 410,000 seniors in the plan will face higher premiums and only be covered for generics in the coverage gap. Or, they can shop for another insurer. In some states, no plan will be available next year that covers brand-name medications in the gap.
Louisville-based Humana's decision to scale back its coverage raises a new complication for Democrats vowing to reform the prescription program, experts say. The party, which will take control of Congress in January, has focused on authorizing Medicare to negotiate lower prices with drug makers.
Humana's decision shows that the actions of insurers -- the private middlemen who deliver the benefit -- also can have a profound effect on seniors' pocketbooks. Negotiations with drug manufacturers may or may not resolve such problems.
"When an insurance company has a plan design that it cannot make money on, it can be pretty ruthless in what it does to correct that," said Robert Laszewski, a healthcare industry consultant. Humana said recently it had paid out $1.33 in benefits for every $1 it took in this year under the PDP Complete plan.
Generic drugs, usually copies of brand-name drugs on which the patents have expired, cost a lot less. But no generics are available for relatively new drugs, including many medicines for conditions ranging from cancer to psychiatric problems.
Moe Tawil, 70, a retired engineer from Manhattan Beach, says he can understand why the insurer would need to raise premiums, but he questions the decision to curtail coverage of brand-name drugs.
"The fact that the plan can significantly change is at best annoying, and at worst it can create quite a problem for some people," he said. "It just causes a tremendous amount of confusion and heartache. You don't buy auto insurance to have them tell you, 'By the way, we're not going to cover collision next year.' "
Tawil's wife, Barbara, is on Femara, a pill taken daily to prevent the recurrence of breast cancer. Considered more effective than tamoxifen, the medication costs more than $700 for a 90-day supply. The Tawils now pay $150 through her PDP Complete plan. There is no generic equivalent for Femara, which is manufactured by Novartis.
