Nov 082011

It’s time to shop for a Medicare Part D Prescription Drug Plan if you are a senior and Medicare eligible. We’ve discussed the various Medicare Part D plan rates offered this year already (see our post about it), but today we wanted to discuss another aspect of that plan that too often seniors don’t consider.  It’s called the “donut hole.” If you don’t know what it is, you should.
You see, Medicare Part D plans like those offered by insurance companies like AARP (UnitedHealth) and Anthem Blue Cross Blue Shield, Empire, or others often offer a low rate plan meant more for healthy seniors that don’t take (and don’t expect to need to take) many medications thr0ughout that enrollment period.  All Medicare D plans receive a stipend payment from the government to cover the costs of medications for seniors. That money is almost like a savings account that goes directly to the insurance company in your name. Every prescription filled gets taken out of that money. When the money is gone, then the patient has to start paying the difference until they reach a catastrophic coverage point. Medicare pays a lot for a while, then almost none for a while, then when the patient has payed thousands, Medicare kicks back in and pays almost everything.

The problem is that place where Medicare stops paying — the hole, or “donut hole” in the coverage. That’s what we are referring to. Many seniors don’t understand this and burn through the government money, then are shocked when their prescription costs surge part way through the year. In many instances this problem can be avoided

Here are some tips on how to get out and stay out of Donut Hole hell.

First, take a look at the type of conditions you and/or your spouse have. People with chronic health conditions like diabetes and respiratory ailments like COPD or asthma are often on a lot of medications.  Consider the types of prescription medications you take, and realize that many of the products that people are on have plenty of alternatives. Some of these alternatives are just as effective, and may be interchangeable. The prices, however, may not be.

Let’s take the case of a person who has diabetes. Diabetics often are on many medications to treat their condition. Some of these can be quite expensive. Diabetes also often leads to “comorbidities” or other problems related to, if not directly attributable  to, diabetes. Some of these can be diabetic neuropathy (often called nerve pain), high cholesterol, and high blood pressure. That’s a lot of conditions!  All of these are problems that can’t be ignored, and that can cause sickness or even death if untreated.

A patient like this will often take any and all medications prescribed by their doctor without question. It’s easy to understand why. Their doctor is trying to treat their problem, and the patient wants to stay well. However, mid year many seniors are tripped up by the donut hole.  What many patients don’t realize is that doctors often have NO IDEA what the medications that they are prescribing cost. They are just choosing a product that they think works. It’s not the doctor’s fault, it’s just how our healthcare system works.

Enter your pharmacist. Having a good relationship with your pharmacy staff and your pharmacist can help you to save a TON of money. Pharmacists know alternatives to the medications that your doctor has chosen. They can recommend those to your doctor. Sometimes, a medication may have a generic alternative that is cheaper that will work just as well — or almost as well. You might say, well, I don’t want something inferior. Well, if the alternative is to stop taking a medication halfway through the year because it went from a three dollar copay to a three HUNDRED dollar copay, well, that might be better in the long run. And many times, the generic product is just as good.

And sometimes, the prices for different generic drugs are greatly different. Again, here your pharmacist might be able to help. Also, sometimes “combination” products exist, where, instead of taking two brand-only drugs, you can take one with both of those drugs in it. Sometimes these will be cheaper. Your pharmacy staff will be able to target products and see which medications are burning through that Medicare D money. Ask them and have them help you and your doctor to find a more affordable plan. And do it EARLY in the year, to preserved that money.

Or consider choosing a higher premium Medicare D plan that doesn’t have a donut hole, or even combine the medicare D plan with a Cigna Medicare Advantage plan with drug coverage.