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Look Before You Leap: Allsup Cautions Medicare Recipients about the Prescription Drug Donut Hole

Knowing prescription drug needs and options is essential for enrolling in the right Medicare plan

Belleville, IL (PRWEB) December 5, 2008 -- Millions of people never hear of the Medicare prescription drug "donut hole" until they've fallen into debt trying to climb out, according to Allsup, a leading provider of Social Security disability, financial and healthcare-related services to people with disabilities. The issue is particularly acute for individuals with disabilities relying on a variety of costly medications to try to manage chronic conditions.

"If you have high prescription drug costs, then you really owe it to yourself to look at what options are available to help you either avoid falling into the donut hole or minimize your exposure," said, Paul Gada, personal financial planning director and product manager for Allsup Medicare Advisor . The service helps people with disabilities choose the best, most affordable Medicare plan to meet their specific needs.

The Dollars before the Donut Hole

The donut hole is a coverage gap in Medicare's standard prescription drug plan. For 2009, the gap begins after the cost of a Medicare beneficiary's prescription drugs, including the patient's own deductibles and co-pays, has reached $2,700. The individual then is responsible for directly paying the next $3,453.75 until total drug costs have reached $6,153.75. At this point, catastrophic coverage sets in and Medicare again begins covering costs.

"Many people are shocked to find out how quickly they actually reach the donut hole," said Gada. "They only look at the costs they've paid in co-pays, which may be a few hundred dollars, not the total cost of the medication. So, suddenly, they find they've reached the $2,700 threshold and now have to go from paying relatively small co-pays to bearing the entire cost of their medications."

Falling into the donut hole has obvious negative financial consequences. It also can result in poorer health, as people choose between paying their basic living expenses and getting the treatment and prescription drugs they need. According to Gada, it's critical for people to manage their healthcare budgets and find the right Medicare plan for their needs.

Minimizing or Avoiding the Donut Hole

Whether an individual chooses a Medicare Part D (prescription drug) plan or a Medicare Advantage plan with prescription drug coverage, they will pay a monthly premium and have co-payments or co-insurance in order to get their prescription drugs.

However, plans vary and cater to different needs better than others. So Medicare beneficiaries need to understand both their prescription drug requirements and their Medicare coverage to best manage their prescription drug costs.

Gada recommends getting answers to the following questions:

  • Are there generic equivalents available for your prescription drugs? Ask your physician. "Your doctor is not thinking about your pocketbook when he prescribes medication. Your health is your doctor's focus," Gada said. "But that is the time to ask about alternatives -- before you have the prescription in hand." The FDA estimates that switching to generic drugs provides a 50-70 percent savings over name brands.

  • Does your Medicare coverage pay for the medications you use, and what are the co-pays? Ask each Medicare plan provider you are considering if they cover each of the specific medications you need. Find out the amount of co-pays. Be specific and try to get responses in writing so that you can calculate the true costs from plan to plan.

  • Is there a Medicare Advantage plan provider who will cover your prescription drug costs during the donut hole? Ask each Medicare Advantage plan provider you are considering if they provide any coverage for prescription drugs during the donut hole. Prescription drug coverage, including generic drug coverage, varies under traditional Medicare Part D plans and Medicare Advantage plans, so it's important to verify what will be covered.

"This sounds easy enough to do, but it can be extremely difficult," Gada said. "Most beneficiaries have dozens of Medicare plan options."

Taking time to be more informed can result in significant savings. "It takes a level of understanding of healthcare insurance to narrow the field down and tenacity -- to wade through the details of the plans or to get on the phone and follow up with providers to get the information you need to make informed choices," said Gada. "We provide this assistance as part of or Allsup Medicare Advisor services because not everyone may be up to the task."

Gada also noted that individuals who still find it a struggle to pay for their medications may want to contact the pharmaceutical companies that make their medications to see if they have a drug assistance program. Additionally, many states also offer state pharmaceutical assistance plans.

About Allsup

Allsup, Belleville, Ill., is a leading nationwide provider of financial and healthcare related services to people with disabilities. Founded in 1984, Allsup has helped more than 100,000 people receive their entitled Social Security Disability Insurance and Medicare benefits. Allsup employs more than 550 professionals who deliver services directly to consumers and their families, or through their employers and long-term disability insurance carriers.

The Allsup Medicare Advisor service provides customized, objective support to help individuals with disabilities navigate the complexities of Medicare and Medicare Advantage programs, analyze the best plan coverage and provider options based on individual preferences, better understand healthcare cost information, and simplify the confusing process of enrolling in a Medicare Advantage plan.

For more information, visit

The information provided is not intended as a substitute for legal or other professional services. Legal or other expert assistance should be sought before making any decision that may affect your situation.

Mary Jung
(773) 429-0940

Dan Allsup
(800) 854-1418 ext. 5760


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