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Because Medicare agents have a large number of products to choose from when deciding what to sell, we explain why offer Physicians Mutual dental plans in the post below.

Dental products provide necessary coverage not offered by original Medicare. Because poor dental health can lead to serious health issues, regular dental checkups can help avoid health problems down the road.

There are 4 different dental plan options

Each plan provides coverage for over 400 procedures. The difference between the plans is the premium and the amount the plan pays for each covered service. There are plan choices to fit any budget.

All plans provide 100% coverage for preventive treatment at an in-network dentist. This includes; an exam, x-rays and a cleaning.

Take a look at the CT dental Brochure

Please note; There is a 12 month waiting period on major benefits.

All plans use the Ameritas network of providers. There are more than 5000,000 provider locations for member to access. All these plans are PPOs so members can receive out of network coverage for services, but it is always better to use in network providers for the best value.

Economy

As you have probably guessed; these plans are the lowest cost plans.

The Economy plans pay 25% of the maximum allowable charge for Basic treatments (fillings) and Major benefits, such as root canals or crowns.

Standard

Standard plans are another affordable option for dental coverage. They provide a payment of 40% of the maximum allowable charge for basic and major treatments.

Preferred

Preferred plans are similar to the other plans. The plan cost is a little more and so is the coverage percentage members receive. These plans provide 55% payment of the maximum allowable charges for basic and major benefits.

Premier

The Premier plans are the highest coverage level available at Physicans Mutual. This plan pays 70% of the maximum allowable charge for covered services..

Click here for product availability Map

A few more reasons to offer Physicians Mutual Dental Plans

These plans do not require members to pay a deductible. All preventative benefits are covered at 100% from day 1. One important aspect of this plan is; there is no maximum on cash benefits like other plans. That makes these plans a fantastic value no matter which plan beneficiaries choose.

Watch a video on the Physicians Mutual Dental plans

It is easy for members to add a vision and hearing rider to any plan. Once added members can use any participating provider.

See why you should offer ancillary products to your clients

Eye exams are covered up to $100 per year per member. The vision correction benefit of $150 includes prescription eyeglasses, sunglasses, sports glasses and contact lenses. There is a 3 month waiting period for this benefit. Members use the VSP network of providers to receive a discounted price for eye exams and lenses.

The hearing benefit provides up to $75 per member for covered hearing exams and as much as $500 per hearing aid per ear after a 12 month waiting period.

Click here for online contracting with Crowe

Understanding common Medicare acronyms is important weather you are getting ready to sign up for Medicare or a Medicare agent. As in any business, understanding the terminology is essential to help navigate the system.

General Medicare Terms

• CMS: Centers for Medicare & Medicaid Services
  The federal agency that administers the nation’s major healthcare programs, including Medicare and Medicaid.
• SSA: Social Security Administration
  The government agency responsible for administering Social Security benefits, including the processing of Medicare applications.

Parts of Medicare

1. Part A: Hospital insurance covers inpatient hospital stays, skilled nursing facility care, hospice care and some home health services.
2. Part B: Medical Insurance covers outpatient care, doctor services, preventative care and DME.
3. Part C: Medicare Advantage plans are an alternative to Original Medicare. They provide the same coverage as Original Medicare and often some added benefits. Private insurance companies offer these plans.
4. Part D: Prescription Drug Plans provide coverage for approved prescription medications. Private insurers offer these plans.

Medicare Plan Types

• MA: Medicare Advantage also called Part C provide the same benefits as Original Medicare (Part A & Part B).
• MAPD: Medicare Advantage Prescription Drug Plan provide the benefits of Original Medicare as well Part D.
• PDP: Prescription Drug Plan provides stand alone coverage of prescription drugs under Medicare Part D.
• HMO: Health Maintenance Organization is a type of Medicare Advantage plan. These plans require members to use a specific network of providers and referrals for specialists.
• PPO: Preferred Provider Organization is a type of Medicare advantage plan that offers out of network coverage. They are a more flexible option than an HMO.
• PFFS: Private Fee-For-Service is another type of Medicare advantage plan. It allows beneficiaries to see any doctor or hospital that accepts the plan’s terms. The costs and coverage are set by the plan.
• MSA: Medical Savings Account combines a high-deductible Medicare advantage plan and a savings account. The plan deposits money into the account each year to pay healthcare expenses before beneficiaries meet the deductible amount.
  

Enrollment Periods

• AEP: Annual Enrollment Period occurs from October 15 to December 7 annually. During this time, beneficiaries can enroll in or change their Medicare coverage.
• ICEP: Initial Coverage Election Period is the period when individuals first become eligible for Medicare benefits.
• SEP: Special Enrollment Period occurs outside normal enrollment periods and provides an opportunity to change plans due to a specific event. This includes things like moving or losing employer sponsored health coverage.

Learn more about Medicare enrollment periods

Notices and Forms

• ANOC: Annual Notice of Change
  A document sent by Medicare plans outlining any changes in coverage, costs, or service areas for the upcoming year.
• EOC: Evidence of Coverage
  A document detailing what the plan covers, how much members pay, and other rights and responsibilities.
• ABN: Advance Beneficiary Notice of Noncoverage
  Is a waiver of liability. A notice given to beneficiaries of Original Medicare when a service or item isn’t expected to be covered, allowing them to decide whether to receive and pay for the service.

Assistance Programs

• LIS: Low-Income Subsidy
  Also known as “Extra Help,” this program assists individuals with limited income in paying for prescription drug costs under Part D.
• MSP: Medicare Savings Program
  State programs that help pay Medicare premiums and, in some cases, deductibles and coinsurance for individuals with limited income.

A few more terms

• DME: Durable Medical Equipment
  Medical equipment like wheelchairs, walkers, or hospital beds that are ordered by a doctor for use in the home.
• EOB: Explanation of Benefits
  A statement from a Medicare plan detailing what was billed, what Medicare paid, and what the beneficiary may owe.
• HIPAA: Health Insurance Portability and Accountability Act
  A federal law that, among other things, protects the privacy of individuals’ health information.

Being well informed helps ensure that beneficiaries and professionals can navigate the Medicare system effectively.

Individuals getting started in Medicare sales or long time agents may be looking for the best FMO for Medicare agents to grow their business.   A good FMO can make all the difference in the world for an agent. They can provide invaluable knowledge, tools and support and expand on the agents value to their community.

Because we offer contracts with all the major carriers as well as many smaller carriers, we ensure the client receives the best coverage to fit their needs. Making sure the clients are happy should the agents top priority. Not only do we work with Medicare products but, we offer ancillary products. This ensures clients can shop for all their coverage in one place. Our ancillary products include dental, vision, final expense and several life insurance options.

Watch a YouTube video to see what we can offer you

When clients get all their coverage needs met in one place, it leads to better retention rates and stronger agent/client relationships. This helps agents maintain their book of business. It also ensures that clients go to the same agent with all their questions.

Click here for online contract and join the team at Crowe

It is easy to get selling with Crowe. There is no need for mountains of paperwork. Just fill out the online contracting kit. You will also need to send copies of your license, E&O , and a void check.  The contract has a section for agents to indicate which companies they want to contract with.  It is that easy.  Agents can easily add carriers to their contract by filling out a link or sending an email to us.

Best FMO for agents – What we have to offer

Agents receive full compensation

Every agent contract we offer is for the maximum allowable commission. Agents receive pay directly from the carriers; we do not take any part of the commission you earn.

Click here for Medicare commissions 2025

Our agents are independent

If you contract with us, you work for yourself and decide what hours you put in.  What you put in to your business is what you will get out of it. Because our agents receive their commission directly from the carriers, you own your book of business.  If you decide to ask for a release, you take your clients with you. Our job is to provide guidance and support when you need it.

Medicare lead program

Our agents are eligible to receive up to $500 per month as reimbursement for Medicare marketing and lead costs.  The only catch is; you must have all your Medicare contracts through Crowe. We do not impose production minimums to start and do not reduce your commission. 

 Click here to learn about our lead program.

Many ways to enroll a client

Due to the fact that we are partners with Pinnacle Financial Services, we can provide free quoting and enrollment tools. This allows clients to enroll in a plan in a way that is comfortable for them.

Voice signature

We offer many tools to quote and enroll that allow agents to use a voice signature. This includes Connecture, Sunfire and My Medicare Bot.

Click here to learn about My Medicare Bot.

Online enrollment with Connecture or Sunfire

Easily access online enrollment tools for Medicare Advantage, Supplement and Part D plans. All our agents have access to a personalized online enrollment platform.  There is no need to meet clients face-to-face if they are not comfortable doing so.  This saves valuable time for everyone when necessary.  Agents can send prospects a link to compare plans and self enroll from either site.

Find out about the updates in Connecture and Sunfire for 2025

Paper application processing 

Because some clients like to use paper applications, Pinnacle is one of the few uplines that still provides our agents application scrubbing & processing.

Additional product quotes

Agents who work with us have free access to Pinnacle’s online quote site.  The site not only quotes and compares Medicare Advantage, Medicare supplement and Part D plans but includes; Final Expense, Term, UL, Hospital indemnity, vision and dental plans.   Take a look at a site demo.

Turn-key seminar program

We offer agents a Medicare seminar program. This is a great option for agents who enjoy presenting invaluable information to those who need it.  Our seminar program allows agents to get out and meet at least 40 to 60 T-65 prospects at each event.  Many prospects are more comfortable when they meet an agent face-to-face and this is a great way to do it.

Each agent has access to a personal portal where the seminar registrants’ contact information is stored. This lets you follow up with those who want your help.  All invites are sent out for you and all you have to do is book a venue, present your information and close the sale!

Learn the Details of Our Seminar Selling Program

Training webinars

We send out weekly invites to any agent who wants to learn about new products and regulations. All our webinars are available on our YouTube channel so you can view them at your convenience.  Our videos cover many topics including:  Sales strategies, enrollment and marketing rules, product knowledge, and how to use the sales tools available to our agents.

Take a look at our YouTube channel for some free training videos.

Additionally:

If you want help growing your book or building an agency, we are here for you.  Agencies working with us can use our programs and tools to recruit and train agents.  This includes our Medicare lead program.  This program is a great help to new agents and provides incentive for them to join your agency.

Please note;  each carrier has specific requirements for the various agency levels.  We are here to help you get to the level you are want to be at.  Up-line levels include GA, MGA and SGA levels.

Learn about our discounted E&O coverage; both agents and agencies can purchase our E&O.

Our E&O covers multiple lines of business including; Life, Health, LTC  & FE as well as Annuities, both fixed and indexed

More Agency Programs and Benefits – Click here

Life Insurance Basics for Insurance Agents

Life insurance is one of the most essential financial products available, providing financial security and peace of mind for individuals and their families. As an insurance agent, understanding the fundamental aspects of life insurance is crucial for effectively educating and assisting clients. This guide will cover life insurance basics for agents to help you decide if adding these products is right for you.

Life insurance is important financial protection that is paid upon the insured’s death in exchange for premium payments. It is a contract between an individual (policyholder) and an insurance company. This financial protection helps cover funeral costs, outstanding debts, daily living expenses, and future financial needs for the designated beneficiary.

Watch our quick YouTube video on life insurance basics

Types of Life Insurance

There are several types of life insurance policies, each one is designed to meet specific financial needs and objectives.

Term Life Insurance

• Provides coverage for a specific period (e.g., 10, 20, or 30 years).
• Offers a death benefit if the insured passes away within the term.
• More affordable than whole life insurance.
• No cash value accumulation.

Whole Life Insurance

• Provides lifelong coverage as long as premiums are paid.
• Accumulates cash value that policy holder can borrow against or withdraw if necessary.
• Premiums remain level throughout the policyholder’s life.

Universal Life Insurance

• Offers flexible premium payments and death benefits.
• Includes a cash value component that earns interest.
• Policyholders can adjust coverage amounts based on financial needs.

Variable Life Insurance

• Allows policyholders to invest the cash value in various investment options (e.g., stocks, bonds, mutual funds).
• Death benefit and cash value fluctuate based on investment performance.
• Higher risk but potential for higher returns.

See why critical illness insurance may be a good choice for your client

Some things to consider

As an insurance agent, it’s important to assess the clients’ coverage needs, financial situation and goals before suggesting a policy. Here are some things to consider:

1. Financial Needs Analysis – Determine how much coverage a client requires based on their income, debts, dependents, and future expenses.
2. Affordability – Ensure the client can comfortably afford premium payments without financial strain.
3. Policy Features – Explain policy riders, such as accidental death benefits, waiver of premium, or critical illness riders, to enhance coverage.
4. Long-Term Goals – Help clients align their life insurance choice with their retirement, estate planning, or wealth transfer strategies.

Are you an agent interested in adding life products; click here for online contract

Educating Clients

Educating clients helps them make informed decisions about life coverage. Be sure they understand all terms in simple language, provide real-life scenarios, and offer personalized recommendations.

Understanding life insurance basics helps insurance agents serve clients effectively. Knowing the types of policies, key features, and client needs, allows agents to provide tailored solutions that offer financial protection and peace of mind.

Selling Medicare plans face-to-face can be very effective, but it requires the right approach to ensure a successful client interaction. Unlike online or phone-based sales, in person meetings allow agents to build trust, address concerns directly, and provide a more personalized experience. Our tips for in person Medicare sales will help agents formulate a sales strategy and expand their book of business.

Do your research

Before meeting a potential client, take the time to understand their specific needs. Having clients fill out a well designed fact finder can provide a roadmap for agents to identify client needs and preferences. Being prepared demonstrates professionalism and allows you to provide relevant options.

Ask questions to help determine the best coverage options

• What are the preferred doctors and hospitals?
• Do they take any prescription medications?
• What is the monthly budget for healthcare expenses?
• Do they travel frequently or spend part of the year in another state?

This goes back to the fact finder suggestion. These insights help tailor recommendations to the unique needs of each individual.

Create a professional first impression

First impressions matter. Dress appropriately, arrive on time, and maintain a friendly yet professional demeanor. Be aware of the client’s needs and preferences and follow all CMS guidelines. Bring all necessary materials, such as brochures, plan comparisons, and enrollment forms, to ensure a smooth meeting.

Form a personal connection

Medicare decisions can be overwhelming for clients. Establish rapport by engaging in friendly conversation and showing genuine interest in their concerns. Building trust makes it more likely they will rely on your guidance and even recommend you to their friends or family.

Learn how to maintain your book of business

Educate rather than sell

Instead of trying to push a specific plan, focus on educating the client about their coverage options. Explain the differences between plan types (Medicare Advantage, Supplement plans, and Part D) in understandable terms. Do not use industry jargon that may confuse clients.

Do not pressure clients to enroll in a plan. Be transparent with all plan benefits and costs. Let prospects consider all information and enroll if they are comfortable. If they choose not to enroll, respect their decision and let them know you are available if they need assistance in the future.

What you need to know before a Medicare sale – Watch a quick YouTube video

Use visual aids and examples

Many clients understand information better when it is presented visually or in a practical context. When possible, use plan comparison charts, benefit breakdowns, and real-life scenarios to illustrate coverage differences and potential costs.

Address concerns

It is very common for clients to have concerns about cost, coverage limitations, or provider networks. Be prepared to address objections with clear explanations of plan benefits, potential cost savings, and alternative options.

Follow all CMS and carrier guidelines

Always adhere to CMS (Centers for Medicare & Medicaid Services) and carrier regulations when discussing plans. Avoid misleading statements, ensure proper documentation, and provide all required disclosures to maintain ethical and legal compliance. This helps protect both the client and the agent in the event questions arise later.

Learn about the Medicare Scope of appointment

Follow Up

A simple follow-up call or email reinforces your commitment to client satisfaction. Check in to see if they have additional questions or need further clarification before making a decision. Agents should also follow up after the enrollment to be sure clients know they are available if any concerns arise later. This helps reinforce the relationship and the client’s confidence in choosing an agent.

Continue learning

Because Medicare plans and regulations change every year, it is important to stay updated on plan details, industry news, and new regulations. This helps you provide the best service to your clients.

Subscribe to our YouTube channel for free training and informational videos

In-person Medicare sales provide agents with the opportunity to build meaningful relationships and offer personalized guidance. By focusing on trust, education, and professionalism, agents can build their book and become valued members of the community.

Are you interested in joining the Crowe team – click here for online contract

Understanding rapid disenrollments and their impact on agents

If you are in Medicare sales, you may hear the term rapid disenrollment. Newer agents may wonder; what are Medicare rapid disenrollments. We explain a little about this term and how it affects agents below.

Although you may have done your best, not every enrollee remains satisfied with their plan choice. When a beneficiary quickly disenrolls from a Medicare Advantage plan, this is known as a rapid disenrollment. While this can be frustrating for the beneficiary, it also has significant repercussions for agents who sell these plans.

What is a rapid disenrollment

A rapid disenrollment occurs when a beneficiary leaves their Medicare Advantage plan within the first three months of enrollment. This happens for a variety of reasons, including dissatisfaction with provider networks, unexpected costs, confusion about benefits, or an agent not properly explaining the plan’s details.

Rapid disenrollments can take place during the Medicare Advantage Open Enrollment Period (January 1 – March 31) or via ann SEP (Special Enrollment Period) if the beneficiary has a qualifying life event.

Why rapid disenrollments matter

For agents, rapid disenrollments can have significant financial and professional consequences:

1. Chargebacks – When a beneficiary disenrolls early, agents often face a chargeback, meaning they must repay some or all of their earned commission from that sale. This can significantly impact an agent’s earnings, particularly if multiple rapid disenrollments occur.
2. Compliance scrutiny – High disenrollment rates may trigger compliance audits by CMS (Centers for Medicare & Medicaid Services) or plan sponsors. If an agent is found to have misrepresented a plan or failed to properly educate the enrollee, they could face penalties or even be barred from selling Medicare plans.
3. Reputation damage – If beneficiaries frequently disenroll from an agent’s recommended plans, it can damage the agent’s reputation in the industry. Clients may leave negative reviews or hesitate to trust the agent in the future.

Join the team at Crowe – fill out an online contract

Reduce rapid disenrollments

• Conduct thorough needs assessments – Before enrolling a client in a Medicare plan, agents should take the time to understand the client’s healthcare needs, budget, and provider preferences. Making sure the plan chosen aligns with these factors reduces the likelihood of disenrollment.
• Explain all costs and coverage – Unexpected costs, such as high copayments or out-of-network charges, often lead to disenrollment. Agents should clearly explain all costs associated with a plan so beneficiaries can make informed decisions.
• Follow Up with Clients – A simple follow-up call after enrollment can address any concerns early and prevent clients from making hasty disenrollment decisions. Providing ongoing support builds trust and reduces confusion.
• Stay Educated on Plan Changes – Medicare plans change annually. Agents who stay updated on plan benefits, provider networks, and formulary adjustments can better guide their clients toward the most suitable options.
• Ensure CMS Compliance – Agents should always follow CMS marketing guidelines to avoid misleading beneficiaries. This includes proper documentation and full disclosure of plan details.

Watch a quick video on the FCC one to one consent rule

Although disenrollment can sometimes be unavoidable, agents who are well educated, transparent, and ethical can reduce its occurrence. By following the rules and understanding clients’ needs, they can protect their commissions, maintain a good professional reputation, and, most importantly, ensure beneficiaries receive the best possible coverage for their needs.

Medicare Part D is prescription drug coverage and is essential for anyone enrolled in Medicare. Understanding when to enroll in Medicare Part D is extremely important for both beneficiaries and agents. Medicare beneficiaries not enrolled on time will be without coverage resulting in a life-long penalty.

Initial Enrollment Period (IEP)

The IEP ( Initial Enrollment Period) is the first opportunity beneficiaries have to enroll in a Medicare plan. If the beneficiary enrolls in Medicare at this time, they should make sure to include Part D coverage. During the IEP, beneficiaries can choose either a stand alone Part D plan or a Medicare Advantage Plan with drug coverage MAPD plan.

The IEP is a 7 month window when a beneficiary turning 65 can enroll in Medicare. It starts three months before the beneficiary’s 65th birthday month and ends three months after their 65th birthday month.

Those eligible for Medicare due to a disability have an IEP. The IEP starts three months before their eligibility date and ends three months after the 25th month of receiving disability benefits.

Annual Enrollment Period (AEP)

The Annual Enrollment Period (AEP), also called Open Enrollment, takes place from October 15 until December 7 each year. During this time, beneficiaries can enroll in a Part D (PDP) plan if they did not enroll during their IEP. For those already enrolled in a PDP plan, this is an opportunity to look at current coverage and change to a plan that provides better coverage. Plan enrollees can switch from one Part D plan to another or enroll in an MAPD plan.

Please note: changes made during AEP take effect on January 1st of the following year.

Special Enrollment Periods (SEPs)

SEPs provide an opportunity to make changes to Medicare coverage. This includes Medicare Part D outside the standard enrollment periods when the following circumstances occur:

1. They move their place of residence and it is outside the service area of their current plan. When this happens, the enrollee is eligible for an SEP.
2. If the beneficiary is eligible for Extra Help, they can change their Part D coverage once during each of the first 3 quarters of the calendar year.
3. When there is loss of creditable prescription coverage (not due to non-payment), they have 63 days to enroll in a new PDP plan. Most commonly, this happens when a beneficiary comes off employer sponsored coverage.
4. In the event a plan leaves the current service area, beneficiaries have 63 days to move to a new PDP plan.

Medicare Advantage Open Enrollment Period (MA OEP) 

This enrollment period is only available to those currently enrolled in a Medicare Advantage plan. It runs from Jan 1 through March 31 each year. During this time, plan enrollees have an opportunity to change their current MA/MAPD plan. The MA OEP allows beneficiaries to change from one Medicare Advantage plan to another Medicare Advantage plan either with or without Part D coverage. They can also disenroll from a Medicare Advantage plan and go back to Original Medicare with the option to enroll in a stand alone Part D plan and a Medicare Supplement.

Watch a quick YouTube video on OEP best practices

Important: beneficiaries must have a guaranteed issue election or pass underwriting to enroll in a Medicare Supplement plan.

Late Enrollment Penalty (LEP)

Those who enroll in Part D coverage when first eligible can avoid late enrollment penalties. The LEP applies to Medicare beneficiaries who go without creditable prescription drug coverage for a period of 63 consecutive days or more once their IEP ends.

CMS calculates the penalty based on how long the beneficiary went without coverage. Once they have that figure, they add it to the monthly Part D premiums for life. This applies even when the enrollee has a $0 MAPD plan. Although those who receive Extra Help do not have to pay the penalty.

It is important to understand Medicare Part D enrollment periods and rules to avoid penalties and ensure beneficiaries have the coverage they need.

At some point, some individuals with prescription coverage may find their prescription drug copay higher than expected. This could mean, the drugs are on a higher tier and therefore the copay is more. Higher tiered drugs are more expensive than lower tiered drugs. Although this can make out-of-pocket expenses significantly greater than expected, beneficiaries can request a tier exception. This may help lower the copay for the medication. In this post, we discuss how to request a tier exception.

What is a tier exception

A tier exception is a formal request individuals send to their insurance provider asking them to cover a drug at a lower cost tier. Typically, each insurance plan has a formulary (list of covered drugs) where they categorize medications into different tiers. Generic drugs are in the lowest-cost tiers and specialty or brand-name drugs in the highest-cost tiers. Individuals who have medication on a high-cost tier and cannot afford their copay can request an exception to lower their costs.

Review the formulary

Individuals should check their insurance provider’s formulary, which is the list of covered medications and their respective tiers. This cost for drugs on each tier is available in the plan’s evidence of coverage. Enrollees can also request a plan formulary from the plan provider or review it on the plan’s website. If the drug is on a high-cost tier, check and see if there are lower-tier alternatives that might work. If that is not an option, a tier exception may provide a way to afford the necessary medication.

Learn about Medicare Part D 2025

Obtain a supporting statement from the doctor

The enrollee’s insurance company will require a supporting statement from the prescribing doctor explaining why lower-tier alternatives are not suitable for the individual. The doctor must specify that:

• The lower-tier medications have been ineffective or would cause adverse effects.
• The requested drug is necessary to treat the specific condition.

Submit a formal request to the insurance carrier

Contact the insurance company to obtain the tier exception request form. The doctor’s office may be able to do this for the patient. Complete the form, attach the supporting statement, and submit it through the insurance company’s designated method (fax, email, mail, or online portal).

Wait for a decision

In the majority of cases, insurance carriers have 72 hours to make a decision on a standard request. If the situation is urgent and the medication is needed immediately, request an expedited review, which requires a response within 24 hours.

If the request is approved

The drug will be covered at a lower cost sharing amount that applies to the new drug tier. In most cases, the approval will last until the end of the calendar year. Beneficiaries may request the drug tier be honored the following year. In the event the carrier does not allow the exception the following year, the plan enrollee can start the process over again or use the Medicare AEP to find a plan that covers the drug at a lower rate.

If the request is denied

If the tier exception request is denied, beneficiaries have the right to appeal the decision. Each plan will provide instructions on how to appeal, which often includes submitting additional medical documentation. If the appeal is still denied, the beneficiary can escalate it to an independent review entity.

Watch a quick YouTube video on Medicare enrollment periods

Requesting a tier exception can help make prescription medications more affordable, but it may require careful documentation and persistence. Those facing high medication costs must work closely with their doctors and insurance carrier to improve their chances of approval.

When navigating health insurance, you come across terms like coinsurance and copays both of which determine how much you pay for medical services. While some people use these terms interchangeably, they have distinct meanings and impact out-of-pocket healthcare costs differently. Understanding the differences between copays and coinsurance can help beneficiaries have a better understanding of how their coverage works.

What is a Copay

A Copay (copayment) is a fixed amount plan enrollees pay for a specific healthcare service. Copays are typically required at the time of service and apply to things like primary care or specialist visits, urgent care visits, and prescription medications.

How Copays Work

• If a health plan has a $30 copay for primary care visits, plan enrollees pay $30 each time they see their doctor, regardless of the total cost of the visit.
• When a plan specifies a $50 copay for a specialist visit, enrollees pay that amount, while the insurance covers the rest of the cost for the visit itself. Please keep in mind; some medical services include additional charges.
• Copays for prescriptions vary based on tiers (generic vs. brand-name drugs). Copays for prescriptions may vary greatly based on the drug.

What is Coinsurance

Coinsurance is a percentage of the cost for medical services, equipment or prescriptions that enrollees are responsible for after they meet the deductible. Unlike copays, which are fixed amounts, coinsurance is a percentage of the total bill.

How Coinsurance Works

• If the plan enrollee has a coinsurance of 20% and receives medical services that cost $1,000, their cost is $200. Their insurance covers the remaining $800, once they meet their annual deductible amount.

Differences Between Copays and Coinsurance

Which is Better: Copay or Coinsurance

Neither is inherently better. Each affects overall healthcare costs in different ways. Plans with higher copays may have lower monthly premiums, making them ideal for those who prefer predictable costs. In contrast, plans with coinsurance may have lower copays. This can result in higher out-of-pocket costs for major medical procedures.

Choosing a Plan

Those who visit doctors frequently may prefer a plan with lower copays to help save some money. It is important to consider any known major medical expenses and focus on a plan that provides a lower coinsurance amount and a manageable deductible. It is also important to be aware of the maximum out-of-pocket limit, which caps the amount enrollees pay each year before approved medical expenses are covered at 100%.

Online quoting and enrollment tools help show plan costs side by side to make choosing a plan easier. Medicare agents; click the links below to see how to run a quote on Sunfire and Connecture, our free agent quoting sites.

Agents see how easy it is to use Sunfire for a quote and an enrollment

Take a look at how to use Connecture for quoting and enrollments

Understanding how copays and coinsurance work helps individuals estimate medical expenses and choose a plan that aligns with their healthcare needs and budget. Carefully comparing these costs can help avoid unexpected bills and make the best health coverage choice for each individual

When you discuss Medicare prescription coverage with clients, understanding prescription drug tiers is imperative. Medicare Part D or Medicare Advantage plans place each drug into a specific tier. These tiers impact how much enrollees pay out of pocket for prescriptions. When clients know the tiers their medications are on, they can make informed choices and potentially save money.

What are prescription drug tiers

Prescription drug tiers are cost levels assigned to different medications within a plan’s formulary (the list of drugs each plan covers). Generally, lower-tier drugs cost less, while higher-tier drugs have higher copays or coinsurance.

Prescription drug tiers

Most Medicare Part D and Medicare Advantage drug plans use a 5-tier system, but some may vary slightly. Here’s a general breakdown:

Tier 1 – Preferred Generic Drugs

• Least expensive tier
• Includes common, low-cost generic drugs
• Lowest copay

Tier 2 – Non-Preferred Generic Drugs

• Slightly more expensive than Tier 1 drugs
• Includes common, low-cost generic drugs
• Higher copay than Tier 1

Tier 3 – Preferred Brand -Name Drugs

• Brand-name drugs that the insurance company has negotiated lower prices for
• Higher copay or coinsurance than generic drugs

Tier 4 – Non-Preferred Brand-Name Drugs

• Higher-cost brand-name drugs
• May require prior authorization or step therapy
• Higher copay or coinsurance than lower tiers

Tier 5 – Specialty Drugs

• Highest cost medications, often for complex or chronic conditions
• Typically require prior authorization
• Coinsurance instead of a set copay. In other words, beneficiaries pay a percentage of the drug cost.

In some cases, the necessary drug is not on the plan’s formulary. In that case, the beneficiary needs to request a formulary exception.

Use drug tiers to your advantage

Check the plan formulary – Every Medicare Part D or Medicare Advantage drug plan has a unique formulary. Look up medications to see which tier they fall into to see which plan is the best option.

Consider generic alternatives – Beneficiaries should ask their doctor or pharmacist if a Tier 1 or Tier 2 generic is available instead of a higher-tier brand-name drug.

Use preferred pharmacies – Many plans offer lower prices when beneficiaries fill prescriptions at “preferred” network pharmacies.

Look into tier exceptions – If a prescribed drug is in a high-cost tier, beneficiaries can request a tier exception from their plan, which may reduce their cost.

Compare plans during open enrollment – Each year, Medicare beneficiaries can review and switch plans during the Annual Enrollment Period (AEP) from October 15 to December 7 to find a plan that better suits their prescription needs.

Prescription drug tiers can significantly impact medication costs, but understanding how they work allows beneficiaries to make cost-effective choices. Always review the plan’s formulary, consider generics, and explore savings options like tier exceptions or different pharmacies. A licensed Medicare agent can help navigate drug coverage costs and plan options.