Pharmacists and advocates for older Americans say they are worried that tens of thousands of low-income Medicare beneficiaries will again have trouble getting medications next month, as they did in January of this year.

Many prescription drug plans are changing benefits. Beneficiaries are changing from one plan to another. New plans are entering the market. Some beneficiaries will find they can no longer use the drugstores they have been using.

“There will be surprises and shocks for some beneficiaries,” said Michael J. Negrete, vice president of the California Pharmacists Association.
About 600,000 poor people are losing the guarantee of extra assistance that covered nearly all their drug costs this year. 

“Starting Jan. 1, 2007, you will no longer automatically qualify for this extra help,” the Bush administration said in letters sent recently to these beneficiaries.
Some may still be able to obtain extra help. But they need to apply to a federal or state agency, and few have done so. 

Pharmacists and insurance counselors say many of the 600,000 beneficiaries will not discover the change in their status until they show up at pharmacies next month. Then they could be charged $25 to $50 or more for drugs that cost them only $3 or $5 this year.

Druggists say they also foresee problems for another group: 300,000 low-income people who will be reassigned to plans chosen at random by the federal government.

Even people who stay in the same plan may face surprises because some of their drugs may no longer be covered. Plans can change the list of covered drugs from one year to the next, dropping some and adding others.

Mark J. Gregory, a vice president of Kerr Drug, which owns 102 pharmacies in North and South Carolina, predicted some snarls and delays for customers next month, but said, “It can’t be as bad as early this year.”

“Some seniors will show up at the pharmacy, unaware they have been reassigned to a different plan,” Mr. Gregory said. “They may find that the new plan no longer covers some of their medications. Others may learn that they no longer have a low-income subsidy, and they cannot afford the new co-payment. In both cases, drug therapy may be interrupted.” 

Mr. Gregory offered this advice: “Beneficiaries should be prepared. If you have any doubt, take action now. Ask questions. Call your plan. Don’t wait till Jan. 1.”

Jennifer Mezey, a lawyer at the Legal Aid Society of the District of Columbia, voiced a similar concern. “Come Jan. 1,” she said, “some low-income people will show up at the pharmacy and be charged full price, and they won’t be able to get their medications.” 

Even if a drug is still covered, Ms. Mezey said, it may be subject to new restrictions limiting the number of pills or requiring doctors to get advance approval for prescriptions.

Federal officials said they were trying hard to avoid a repetition of the problems that overwhelmed pharmacists 11 months ago.

With a year’s experience, they said, pharmacists, insurers and beneficiaries know what to expect. Medicare has upgraded its computer systems. Insurers have hired more people for telephone call centers. 

“Lessons have been learned,” said Kathleen M. Harrington, a spokeswoman for the Medicare agency.

Beneficiaries have until Dec. 31 to pick a plan. The Bush administration is urging people to act by this Friday, to avoid delays on Jan. 1.
E. Timothy Marks, co-owner of Excel Drug, a pharmacy in Waldport, Ore., said beneficiaries should be prepared for “problems somewhat similar” to those they experienced early this year.

“The plans are too complicated for some of the elderly to understand,” Mr. Marks said. “Many low-income beneficiaries eligible for Medicare and Medicaid are unaware of the procedures and changes that will affect their drug coverage.”

In the chaotic first weeks of the drug benefit this year, many pharmacists gave away drugs, and many states established emergency assistance programs for low-income people who could not get the drug coverage promised by Medicare. New York and other states have curtailed those programs.

William P. Scheer, chairman of the Pharmacists Society of the State of New York, who owns a drugstore in the Bronx, said: “Some people will go cold turkey on Jan. 1. They will go without needed medications that they have been receiving under the state program.”

The New York State Health Department is sending a “reduction of benefits notice” to people who receive both Medicare and Medicaid. It says the state will no longer cover their drugs, with a few exceptions.

New York officials are urging doctors to help patients get coverage through Medicare. Doctors could, for example, rewrite prescriptions or ask Medicare to make an exception for a particular drug and a particular patient. 
California is continuing its emergency program through Jan. 31.

“We anticipated that there could be problems in January,” said Stan Rosenstein, the Medicaid director in California. “So we kept the program available as a safety net. The governor and the State Legislature did not want any possibility of disruption.”

Mr. Rosenstein said he was most concerned about 85,000 Californians who were losing automatic eligibility for Medicare’s low-income subsidy. “It could be a surprise when they go from paying $5 co-payments to having a $250 deductible,” he said.

The Bush administration has repeatedly advised beneficiaries that they do not have to take any action if they are satisfied with their current drug coverage.
But insurance counselors and health care lawyers say most people can save money by switching plans in 2007.

Katrina A. Eversole, an insurance counselor at the Washington County Commission on Aging in Hagerstown, Md., said she had helped 50 beneficiaries in the last week.

“In most cases,” Ms. Eversole said, “we are signing them up for new plans and saving them a great deal of money. We can often find a plan whose total annual costs will be just half of what they would have to pay for their current plan in 2007.”