The new Medicare prescription drug benefit could mean higher costs, not greater benefits, for thousands of low-income Pennsylvanians in state drug assistance programs who also belong to certain Medicare managed care plans.

Many of the Medicare Advantage plans, including those offered by market giant Highmark Inc., are adding the new Medicare drug coverage, known as Part D, and raising the monthly premiums paid by plan members.

But Medicare Advantage members in PACE or PACENET, the state's drug assistance programs for low-income people 65 and older, arguably don't need Part D because they already have good drug benefits. So they will have little choice but to pay extra or switch to other coverage.

Changing to another plan, even one offered by the same company, can be a difficult decision. Some companies are offering Medicare Advantage plans that do not include Part D coverage, but may require consumers to pay higher copays than they currently pay for certain medical services.

Reports of the higher copays have been coming in from around the state, said Jack Vogelsong, coordinator of the state's APPRISE program, which provides health insurance counseling to Medicare recipients.

The situation is "really disenfranchising to the PACE and PACENET recipients," Mr. Vogelsong said. "It's raising their out-of-pocket costs, and this is a population least able to pay those expenses."

Officials for some health plans note that the PACE program may pick up the added costs of Part D for PACE and PACENET recipients.

Tom Snedden, PACE program director, said PACE officials hope to do that eventually. But seamless coordination of PACE and PACENET benefits with some Part D plans may not occur right away, he said, and the state cannot pay the monthly Part D premiums for PACE and PACENET members without legislative approval.

More than 75,000 PACE and PACENET recipients in Pennsylvania are in Medicare Advantage plans, he said.

For Louise Fiumara, 67, of Blackridge, the situation has been wrenching.

She and her husband, John, 80, receive coverage through PACENET and are enrolled in Highmark's SecurityBlue Standard plan, which currently does not offer drug benefits and costs each of them $20 a month for medical coverage.

But Mrs. Fiumara received a letter from Highmark earlier this month indicating that the monthly premium will increase next year. The medical share of the premium will increase to $26.77 and the Part D benefit will cost $18.23. The $45 total premium would more than double their monthly cost to participate in the plan.

Mrs. Fiumara said paying the higher amount would be difficult, noting that they have a house payment, a car payment and monthly costs exceeding $250 for medications, even with help from PACENET.

Highmark is offering a Medicare Advantage plan, SecurityBlue Value, without Part D coverage and with no monthly premium. But the copays for hospitalization and certain medical tests are more than what the Fiumaras now pay or would pay under the SecurityBlue Standard plan.

Their current Standard plan, for example, requires no copays for inpatient services provided by hospitals in the plan's network, and no copays for lab services or X-rays, provisions that will continue in the new plan offering Part D benefits. SecurityBlue Value, however, will require $250 for each Medicare-covered hospital stay up to a maximum of $500 a year, and $20 to $50 for each lab service or X-ray visit.

Mrs. Fiumara, who had a stroke two years ago, has diabetes and other health problems and takes nine medications daily, said she might consider investigating Medicare Advantage plans offered by another company. But she worried that she and her husband, who has diabetes, congestive heart failure and back problems and takes 15 medications a day, might not be able to keep their current doctors.

Medicare Advantage programs, like other managed care programs, often have lower out-of-pocket costs than traditional Medicare, but typically require enrollees to obtain services from a network of doctors, hospitals or other medical providers.

"I don't know what I'm going to do," Mrs. Fiumara said.

PACE and PACENET recipients who receive coverage through HealthAmerica face a similar situation.

HealthAmerica's current Advantra HMO Silver plan in Allegheny County, for example, offers no drug benefits and has no monthly premium. The plan has a $100 copay for each stay at a network hospital and no copays for X-rays, lab tests or radiation therapy.

The new Advantra Silver plan, which includes Part D benefits and has a $54 monthly premium, offers the same hospital copay and also has no copays for the diagnostic tests and radiation therapy visits.

But a new plan that will not offer Part D benefits, Advantra MA Only, has a $20 premium and will require $250 for each stay at a network hospital. There are no copays for lab tests, but copays from $10 to $50 for each X-ray visit. Patients also have to pay 10 percent of the cost of each radiation therapy service.

Pauline Degenfelder, vice president and general manager of Medicare operations for HealthAmerica, said about 1,400 people currently are in the HMO Silver plan in Allegheny County. She did not know how many of those people are PACE or PACENET recipients.

She said officials assumed that few people would be interested in Medicare Advantage plans that offer only medical coverage, and the company was unable to offer a medical-only plan next year with benefits comparable to those in the HMO Silver plan.

"The whole idea was to focus on the prescription drug benefit and include it into our basic plans," she said.

Highmark officials said about 50,000 people are in its SecurityBlue Standard plan in Allegheny and 16 other Western Pennsylvania counties. Company officials were unsure how many of those people are PACE or PACENET recipients.

In Allegheny and other Western Pennsylvania counties, UPMC Health Plan is offering a Medicare Advantage plan without Part D benefits, UPMC for Life HMO, that offers medical benefits similar to those in an existing plan.

Some plan officials noted that many PACE recipients could qualify for federal subsidies that would cover much of their cost of receiving Part D and could give them lower copays for prescription drugs. PACE officials estimate that about 80,000 people would qualify for full subsidies.

But 220,000 other people in PACE or PACENET may qualify for only partial subsidies, or no subsidies at all. Mr. Snedden said that enrolling those people in Part D eventually could lead to additional state savings. But for now, he advises those people not to apply for Part D.

While PACE will be able to cover higher Part D prescription copays or any coverage gaps, lawmakers will have to take action for the state to pay the program's monthly drug premiums for PACE and PACENET recipients, Mr. Snedden said.

Denise Grabner, a Highmark spokeswoman, said the company would support that change. When the new plans were filed with the federal government, she noted, company officials believed PACE would coordinate its benefits with Part D and pay the federal program's drug premiums for PACE and PACENET members.

Mr. Vogelsong said that in the near future, PACE and PACENET recipients have other options besides paying more to have Part D coverage, though they may need one-on-one assistance to find good alternatives.

In some cases, he said, recipients may be able to keep their out-of-pocket expenses low by moving to traditional Medicare and getting a Medicare supplemental policy.