In Washington, Bush administration officials say Medicare's new prescription drug program is humming along smoothly, filling more than three million prescriptions a day and cutting costs by an average of 50 percent for each beneficiary. But here in the Rio Grande Valley, the picture is different. 

Many patients say they have difficulty getting the drugs they need. Pharmacists, swamped with questions and complaints from beneficiaries, have run into many practical problems as they try to navigate a complex program administered by dozens of prescription drug plans, each with its own policies and procedures. 
Doctors and pharmacists are struggling to figure out which drugs are covered by which plans.

"Intellectually, the program is a good idea," said Dr. E. Linda Villarreal, a former president of the Hidalgo-Starr County Medical Society. "But there's been total chaos and confusion among most of my patients, who do not understand the system and how to work it."

While acknowledging that there were problems at the beginning of the program, the administration has said in recent weeks that those issues have abated. But for Republican and Democratic lawmakers alike, concerns surrounding the benefit have special resonance heading into the midterm elections in November.

Jose M. Flores, a Medicare beneficiary who lives outside McAllen, used the new drug benefit four times from January to April to purchase Byetta, an injectable medicine for diabetes. Each time he paid $40.

So when he went to the pharmacy on May 25, he was dismayed to be told that he owed $167.56 for the next month's supply. Mr. Flores had reached the notorious gap in Medicare's drug coverage. He had to pay the full price of Byetta. His Medicare drug plan paid nothing.

"It's almost useless," said Mr. Flores, a 66-year-old school bus mechanic who was interviewed at his home in La Joya, Tex. "I'm paying the premium, but not getting protection."

In coming months, millions of beneficiaries will have similar experiences, as the cost of their drugs reaches the initial coverage limit of $2,250. Like Mr. Flores, they will have to pay the full cost of each medicine until their out-of-pocket costs reach $3,600. At that point, Medicare coverage resumes, paying 95 percent of the cost of each prescription.

On May 2, Mr. Flores paid $20 for Plavix, a blood thinner used to reduce the risk of heart attack and stroke, and Medicare paid $109.62. But when he refilled the prescription at the end of May, he was in the coverage gap, so he had to pay the full amount, $129.62.

Mr. Flores is angry with Medicare, with his drug plan and even with the pharmacists who try to help him. He says no one told him about the coverage gap when he signed up.

Vanessa M. Recio, a pharmacist at Saenz Medical Pharmacy in Mission, Tex., said: "All I do all day is talk to angry patients. I process insurance claims and try to solve problems with Medicare."

Texas has 47 Medicare drug plans, with different premiums, co-payments and lists of covered drugs, known as formularies. 

"Each plan has its own unique problems," said Jaime R. Solis, a co-owner of Lee's Pharmacy in McAllen. "There's no central place we can call to resolve the problems."

Pharmacists play a special role in border communities like this. When people are sick, they turn to them for advice. In south Texas, as in parts of Mexico, "pharmacists are primary health care providers, especially for the poor," said Marvin D. Shepherd, a professor at the University of Texas College of Pharmacy.

Many beneficiaries here are low-income Mexican-Americans. Some barely understand English, much less the concept of a deductible, co-payment, formulary or coverage gap.

Ramiro H. Barrera, a co-owner of Richard's Pharmacy in Mission, said: "The new Medicare program is a full-time job. We are swamped with requests for help from beneficiaries."

Gilbert Tovar, who runs Lindberg Pharmacy in McAllen, said he had expected the problems to end after May 15, the deadline for people to enroll. But he said, "The logistical nightmare continues because dual eligible beneficiaries — those eligible for both Medicare and Medicaid — can switch plans every month." 

President Bush acknowledged last year that it could be "a daunting task" to select a drug plan from the many available. But Medicare officials said the benefit would be easy to use.

A CBS News/New York Times poll conducted in early May found that, of people 65 and older, 75 percent said the new program was difficult to understand. And many Texans are still struggling.

"It's as if they threw us into college with only a first-grade education," said Raul R. Ramirez, 53, a licensed vocational nurse who qualified for Medicare after being disabled by two heart attacks and a mild stroke.

In some ways, beneficiaries are better off than in the past. Dr. Antonio Falcón, a family doctor in Rio Grande City, Tex., said: "A lot of patients who used to go to Mexico to get their medications are now getting them here. That's a great thing for patients who live along the border."

Bush administration officials say that low-income people like those in McAllen stood to gain most from the new program because they were often eligible for extra help. Medicare officials said they were trying to solve the practical problems reported by pharmacists here. And they said that a typical beneficiary would save at least $1,500 before reaching the gap in coverage.

Under the Texas Medicaid program, low-income beneficiaries were limited to three prescriptions a month. They have no such limit under Medicare, but must pay $1 to $5 for each prescription. Under Medicaid, by contrast, they had no co-payments for drugs.

Competition among Medicare drug plans drove down premiums, but has complicated operation of the program. Pharmacists here say that most of their low-income Medicare customers have insurance cards from several Medicare drug plans
. 

"They come in and ask, 'Which card should I use?' " said John P. Calvillo, a pharmacist at the Cornerstone Pharmacy in Edinburg, Tex., outside McAllen.
That question is not always easy to answer. "Doctors and pharmacists often have trouble finding out what drugs are on the formularies," Mr. Calvillo said. "It's a crapshoot every day."

Typically, a doctor writes a prescription, and the patient takes it to a pharmacist, who submits a claim to the insurer. In many cases, the doctor learns the drug is not covered only after the claim is rejected. The doctor and the pharmacist may repeat the process three or four times until they find a drug that is covered.

"This is a huge problem," Ms. Recio said. "In many cases, when doctors write a prescription, they do not have a list of what medicines are covered. They don't even know what plan the patient is in."

The new program began with a 90-day transition period. In the first three months of the year, Medicare drug plans covered virtually any drugs that patients had been taking. Since April 1, they have been enforcing more limits and restrictions.

Nidia L. Villarreal, president and owner of the Med-Aid Pharmacy in Edinburg, said many patients had experienced significant delays in getting medications because their doctors had to seek exceptions or obtain "prior authorization" from a Medicare drug plan.

Many doctors are eager to help patients. A few use handheld devices loaded with the formulary for each plan. Some check the Internet to see which drugs are covered by a particular plan. But others said they did not have time to do such research.

Jessica Riojas, a pharmacy technician at Lee's Pharmacy, said: "Some doctors are unwilling to call insurers to request prior authorization for a drug. It's a hassle for them. They say they are too busy."

Some problems are well known to federal officials. Many beneficiaries told the government to withhold Medicare drug premiums from their monthly Social Security checks. But Social Security did not always act promptly on such requests.

John R. Morris, 83, a retired salesman in Mission, said he was annoyed when four months' worth of premiums — more than $155 — was deducted from one month's Social Security check.

Other problems are less well known. Beneficiaries receive monthly statements from Medicare, listing the prescriptions they have filled and the amounts spent on their behalf. Insurers sometimes jumble the claims filed for different beneficiaries.

Nine of Mr. Morris's drugs showed up in the latest monthly statement for his wife, Joan D. Morris. As a result, her drug spending appeared much higher than it actually was. If the error goes uncorrected, she will reach the coverage gap sooner than she should.

The new drug benefit is potentially a boon to low-income people because they can get extra help with their drug costs. But more than half of the applications for extra help have been rejected, often because a person's assets or income slightly exceeded the federal limits. Many of these beneficiaries — like May A. Phares, 95, of McAllen — mistakenly concluded they were ineligible for the drug benefit, which is available to everyone on Medicare, regardless of income.

But Ms. Phares persisted. After Social Security twice rejected her applications for extra help, she enrolled in a drug plan, and she is glad she did. "The benefit is working fine," Ms. Phares said, noting that her monthly drug costs had dropped to $167, from $500.