JANE GREIG

Feeling lost and overwhelmed about the drug plan?

We can point you toward the right path.

What do more than 2.2 million Texans have in common? They are 65 or older and therefore eligible for the new, complex Medicare Drug Plan to help pay for prescriptions. (The plan also covers younger, disabled individuals.)

And, oh yes, many seniors are confused by the process, by the changes and by the choices. Who wouldn't be? Add one underage but interested party — me — to the list of those initially confused by the program details.

Medicare now offers drug-cost assistance through private insurers, not an additional governmental administrative entity. The insurance companies must cover some drugs in all the therapeutic categories outlined by Medicare and all drugs in a select few categories. Some offer more coverage and additional drugs, but the monthly premium might be higher.

Normally I can tell you where to find a good brass finisher, dry cleaner or fabric reweaver. Can I tell you which of the almost 50 Texas insurers in the prescription drug plan to select? No. Can I point you in the right direction? Yes.

The confusion and questions prompted by implementation of the new Medicare plan are not unfamiliar. "In the 1960s, the original Medicare benefit was marked by challenges and difficulties, just as the new drug benefit is today," says Jennifer Harris, spokeswoman for Medicare Rx Education Network of Texas, a nonprofit information group.

Do you know what a formulary is? How about a dual eligible? A doughnut? (Bet you thought that was a bakery item.) No? Neither did I several weeks ago when I started looking into the plan for this article. Whether you, family members or friends are eligible, it is time to understand the basics of the Medicare prescription drug program, insurance that covers both brand-name and generic prescription drugs for everyone with Medicare at participating pharmacies.

What the heck is Medicare Part D?

It is the program created by the Medicare Prescription Drug Improvement and Modernization Act in 2003 to provide drug coverage for seniors and disabled individuals. Enrollment began in November. Existing Medicare plans (Parts A, B, C) generally cover hospital and in-patient services, doctor visits, outpatient services, durable medical equipment, etc.

Under the new drug coverage rules, anyone 65 before Feb. 1 must select an insurer before May 15. Generally, you may change insurers annually in the open enrollment period. Some clients may change more frequently.

Who is eligible?

If you are eligible for Medicare, you are eligible for this program — regardless of income, health or current prescription expenses.

Almost all of the 4,300 retail pharmacies in Texas have signed up for at least one of the insurance plans. "Most pharmacists want to serve their patients and try to sign up for the plans their patients have signed up for," says Kristie Zamrazil, spokeswoman for the Texas Pharmacy Association.

So what is the hubbub about?

Several issues.

The coverage start date, Jan. 1, of the program had some hiccups for early enrollees.

In some cases, those without proper paperwork could not have prescriptions filled. Verification lines were clogged.

Seniors must do their homework in selecting an insurance plan. Choice can be confusing.

Not all plans cover all drugs. A plan is required to offer a minimum of two products in each of the 146 categories of drug therapeutics, says Capt. Gary Blair, regional pharmacy officer for the Centers for Medicare & Medicaid Services. In six categories (antidepressants, antipsychotics, anticonvulsants, antiretrovirals, antineoplastics and immunosuppressants), the plans are required to cover all FDA-approved available drugs.

Not all pharmacies work with all plans.

So a consumer must examine the price of current drugs and factor in a preferred pharmacy when selecting a provider.

What is the basic Medicare plan? Its cost per year?

In some ways the program is familiar.

As in traditional insurance plans, there is a monthly payment and a deductible. In addition, you pay a percentage of drug costs after the deductible, up to a point. That point is generally $2,250.

This is where the doughnut hole or coverage gap begins — in which a beneficiary pays 100 percent of medication costs. The other side of the doughnut is at $5,100 total prescription drug spending, when coverage begins again with a co-payment by the beneficiary.

Bottom line? You are on your own for prescription drug expenses between $2,251 and $5,099.

What is magic about $2,250? It's an average, a benchmark.

"In 2003, total prescription drug costs for people with Medicare were $95 billion ($2,318 per person) and the Congressional Budget Office estimates that . . . 16 percent of people with Medicare (6.56 million individuals) had prescription drug costs exceeding $4,000," according to Medicare Rights, a nonprofit organization.

Here's the breakdown for most plans. You will pay:

* a monthly premium (national average of $32.50)

* $250 deductible for drugs

* co-pays of 25 percent for drug expenses between $251 and $2,250

* 100 percent of drug costs between $2,251 and $5,100

* 5 percent (or a co-payment) of drug costs above $5,101 (catastrophic coverage). Your expenses for drugs not covered by your plan do not count toward your deductible or doughnut hole spending.

How do I decide on an insurance plan?

Shop around. Before you compare plans, write down the following:

* Your annual prescription drug spending. Call your pharmacist if you need details.

* The name and dosage of each prescription drug you take.

* The name and ZIP code of the pharmacy you prefer.

* The details of your other prescription drug benefits and plans.

An electronic prescription drug finder helps you pick a plan based on the information you provide. Visit www.medicare.gov or call (800) MEDICARE (800-633-4227) for information.

Call 211 for dates and times of information seminars.

But should I enroll?

You aren't required to join any Medicare plan, and you shouldn't join until you are sure how it would affect your retiree coverage.

In some cases, if you join a Medicare drug plan, you could lose your retiree health coverage as well as your prescription drug coverage from your private insurer. On the other hand, in many cases your retiree plan will work with Medicare to provide your prescription drug coverage. The Medicare drug plan provides incentives to employers for every person for whom company drug coverage is maintained, if that coverage is at least as good as Medicare coverage, says Sandra Hall, regional health insurance specialist at the Centers for Medicare and Medicaid Services.

When can I enroll?

How old are you? Enrollment periods are three months before and three months after the birth month in which you turn 65. Enrollment has been staggered for the start of the program. If you already were enrolled in Medicare through January, the drug program enrollment ends May 15. If you become eligible for Medicare in February, enrollment ends May 31. March birthdays return to the traditional seven-month enrollment window.

What happens if I do not enroll?

If you eventually enroll, you could pay a penalty for not enrolling when first eligible.

The premium penalty is at least 1 percent (based on the national average premium) for every month you delay. This penalty is added to the monthly premium you pay for the drug plan — for the rest of your life. (Some exceptions are made for low-income patients.)

Those with creditable insurance coverage (drug coverage at least as good as that provided by Medicare's drug benefit) will not be charged the penalty.

So where is Texas in all this clamor?

Forty-seven plans are available to Texans, Hall says. But the challenge in Texas is geography and getting information to all 254 counties — some of which are rural and sparsely populated.

Texas is on par with the nation at the moment with 55 percent of the state's eligible seniors in some type of drug coverage plan.

Change for Medicaid patients as well?

For Medicaid, which helps with medical costs for low-income people, Texas, like other states, is transferring the bulk of the drug benefits to the new Medicare drug plan. (In the Medicaid program, the federal government and the states shared the cost of drugs in a 60/40 split.) Meeting the needs of these individuals is no small task. Before the start of the Medicare Part D program, Texas Medicaid spent $66.4 million ($26.5 million from the state) in an average month on prescription drugs for 342,605 clients, reports Geoff Wool, spokesman for the Texas Health and Human Services Commission.

Medicaid coverage for other medical services and nonprescription drugs will continue with the state paying a 40 percent share. (Those whose health care is covered by both Medicaid and the Medicare drug plan are called dual eligibles.) The federal government has agreed to reimburse states for drug costs incurred due to initial glitches in switching people to the Medicare system.

However, the funding of prescription drugs for dual eligibles might be litigated as some states, including Texas, question whether the federal government can legally require states to continue to pay a portion of these drug costs.

Contact Jane Greig at P.O. Box 670, Austin 78767; (512) 445-3697; e-mail jgreig@statesman.com or fax (512) 445-3968. For more Jane Greig, visit www.statesman.com/life/greig.

Tell me more: resources

* Medicare, (800) MEDICARE (633-4227) or www.medicare.gov for information and prescription drug plan finder

* Area Agency on Aging of the Capital Area, a nonprofit agency, 916-6062, (888) 622-9111 or www.aaacap.org

* Texas Department of Aging and Disability Services, 438-3011, www.dads.state.tx.us

* Health Information, Counseling and Advocacy Program, (800) 252-9240, for counseling and assistance

* Centers for Medicare and Medicaid Services regional office, (214) 767-6401 or cms.hhs.gov/RegionalOffices.

* Centers for Medicare and Medicaid Services, www.cms.hhs.gov

* Medicare Today, medicaretoday.org or (866) 723-0416

* American Association of Retired Persons, www.aarp.org

Rx: Learn one new word per day

* Formulary: A list of certain drugs and their proper dosages. In some Medicare plans, doctors must order or use only drugs listed on the health plan's formulary.

* Doughnut hole: The part of the drug benefit in which beneficiaries pay 100 percent of their medicine expenditures.

* Dual eligible: Persons entitled to Medicare who are also eligible for Medicaid.

* IEP: Initial enrollment period.

* MMA: Medicare Prescription Drug, Improvement and Modernization Act (Medicare Modernization Act).

* Medicare Part A: Coverage for hospital and in-patient services.

* Medicare Part B: Coverage for doctor visits, outpatient services, durable medical equipment.

* Medicare Part C: Makes Medicare services available through private plans (HMO, PPO, etc.).

* Medicare Part D: Coverage for prescription drugs.

Open wide: Top 10 drugs prescribed to seniors

Here's the list of the drugs most prescribed to seniors in 2004 and what these drugs do.

* Plavix, antiplatelet agent to prevent heart attacks and strokes

* Lipitor (10 milligrams), lipid-lowering agent for high cholesterol

* Fosamax, osteoporosis treatment

* Norvasc, calcium-channel blocker for high blood pressure and angina

* Protonix, gastrointestinal agent

* Celebrex, anti-inflammatory and analgesic for arthritis

* Zocor, lipid-lowering agent for high cholesterol

* Nexium, gastrointestinal agent

* Lipitor (20 milligrams)

* Prevacid, gastrointestinal agent

Source: Families USA, 'Lessons Learned from the Discount Card'

Got your number

* 1.4 million: the number of Medicare-eligible Texans with prescription drug coverage.

* 1 million: the number of prescriptions pharmacists are filling nationwide per day for Medicare beneficiaries.

* 80: percent of all seniors who take at least one prescription drug daily.

* 3.6 million: number of people who were enrolled in the new Medicare drug plan by Jan. 17.

Source: Centers for Medicare and Medicaid Services, American Federation of State and County Employees

Ask away

Still have questions about the intricacies of Medicare Part D? E-mail Washington bureau reporter Larry Lipman at medicaremailbag@coxnews.com with your questions.