Blog

Each year, Medicare eligible indivduals wonder which type Mediare plan will cover their helath care needs best. Many beneficiareis wonder if they should enroll in a Medicare Supplement or a Medicare Advantage plan. Although both options provide comprehensive coverage, it is important for individuals to consider their needs and budget to make the best choice. In this post, we will go over some ways to decide the best candidates for MAPD Plans.

People Who Want All-in-One Coverage

MAPD plans are good for; anyone who prefers having all their healthcare benefits managed under a single plan. Plan enrollees only need to carry one ID card and pay for Part B and 1 plan premium. Although, some plans do not even charge a premium.

Private insurers offer Medicare Advantage plans (Part C) and bundle together:

• Part A (hospital coverage)
• Part B (medical insurance)
• Often Part D (prescription drug coverage)
• Plus extra perks like vision, dental, hearing, and wellness benefits

Budget-Conscious Individuals

Many MA plans offer low or even $0 monthly premiums. This is in contrast to Medigap plans (used with Original Medicare), which usually have higher premiums.

While enrollees are still responsible for copays and out-of-pocket costs, Medicare Advantage plans have annual out-of-pocket maximums. The maximums provide financial protection Original Medicare alone doesn’t offer. In other words, these plans are a great choice for those on a fixed income trying to cap their annual healthcare costs.

People Who Don’t Travel Often

Because Medicare Advantage plans generally have local provider networks, enrollees must see doctors and hospitals within the plan’s service area for non-emergency care.

These plans are a good choice for individuals who don’t travel often and usually receive care in their local area. MAPDs might not be a good fit for those who live in multiple states throughout the year.

Those Who Value Extra Benefits

Because Medicare Advantage plans usually offer additional benefits beyond what Original Medicare provides, some people prefer them over other options.

Some of the additional benefits (not included in Original Medicare) plans may offer are:

• Dental exams
• Vision exams and an eye wear allowance
• Hearing exams and hearing aid coverage
• Gym memberships
• Transportation to medical appointments
• OTC items
• Healthy food cards

Please note; this list varies by carrier plan type and area. Not all benefits are included in every plan.

Comfortable with Managed Care

Many Medicare Advantage plans involve managed care structures, like HMOs or PPOs, that coordinate your services and may require referrals or prior authorizations.

People who are comfortable navigating provider networks, or calling their plan for care coordination support may find these plans are a good option.

Those in Good Health

Because MA plans often come with copays for services, they may be more cost-effective for individuals who don’t expect to need frequent medical treatment. In other words, Medicare Advantage plans may be a good fit for healthy retirees who normally see a doctor a few times a year for annual checkups or minor services.

Best Candidates for MAPD Plans

Choosing the right Medicare plan depends on personal health needs, budget, and lifestyle. A Medicare Advantage plan can offer convenience, cost savings, and extra benefits,, only if it aligns with how much and where helathcare is needed.

Before enrolling, consider:

• Current doctors (are they in the plan’s network?)
• Medications (are they covered?)
• How often you travel
• Comfort level with managed care.

Medicare Advantage plans are not one-size-fits-all, but for the right person, they can be a useful, value-packed healthcare solution.

Agents click here to learn how Connecture and Sunfire can make quoting and enrollment easier

Before switching or enrolling for the first time, be sure to review options carefully. It is important to check each year during Medicare’s Annual Enrollment Period (AEP) for the plan that best suits current health care needs and budget. A licensed Medicare agent can provide options and help find the most suitable coverage option.

For individuals receiving SSDI (Social Security Disability Insurance), transitioning from SSDI and aging into Medicare is an important milestone. Although most Medicare beneficiaries become eligible at age 65, SSDI recipients qualify for Medicare after a 24-month waiting period. Understanding how SSDI benefits interact with Medicare eligibility helps ensure a smooth transition and access to essential healthcare services.

SSDI and Medicare

Social Security Disability Insurance (SSDI) provides financial assistance to individuals who are unable to work due to a qualifying disability. After receiving SSDI benefits for a period of 24 months, individuals become eligible for Medicare, regardless of age. This allows disabled individuals to access crucial medical care without waiting having to wait until they turn 65.

SSDI Recipients Medicare Milestones

24-Month Waiting Period: Most SSDI recipients must wait 24 months from the date they start to receive disability benefits before Medicare coverage begins.

Automatic Enrollment: After the waiting period, eligible individuals are automatically enrolled in both Medicare Part A and Part B.

Early Medicare: Individuals with specific conditions, such as End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis/Lou Gehrig’s Disease (ALS), automatically qualify for Medicare. They do not have to wait the standard 24-months.

SSDI Recipients and Medicare Coverage

Once enrolled, SSDI beneficiaries have access to Medicare benefits including:

Medicare Part A: Covers inpatient hospital care, skilled nursing facility stays, hospice care, and some home health services.

Medicare Part B: Provides coverage for outpatient medical services, doctor visits, preventive care, and (DME) durable medical equipment.

Optional Medicare Part D: These plans provide prescription drug coverage; are not part of Original Medicare and are offered by independent insurers. SSDI recipients can choose to enroll in these plans separately.

Medicare Advantage or Supplement Plan

SSDI recipients can choose to:

Keep Original Medicare (Parts A & B) and add a Medicare Supplement (Medigap) plan to help cover out-of-pocket costs. Plase note; Medigap options may be limited before age 65.

Enroll in a Medicare Advantage (Part C) plan, which often include additional benefits such as; prescrption drug coverage, dental, vision, otc, transportation and more.

Purchase a stand alone Medicare Part D plan those who choose to stay in Original Medicare either with or without a Medigap plan, may purchase a PDP plan to cover prescription medications.

Aging into Medicare

When SSDI recipients reach 65, they transition into the standard Medicare program. This gives them new coverage options and opportunities.

Medicare Supplement Open Enrollment Period

SSDI recipients under 65 have limited Medicare Supplement options because not all states require insurers to offer plans to those under 65. However, once the beneficiary turns 65, they enter a six-month Medicare Supplement Open Enrollment Period. During this time, they can choose any Medigap plan available in their state without medical underwriting. This is an important opportunity to purchase additional coverage without being denied due to pre-existing conditions.

Learn more about Medicare Supplement guaranteed issue rights

Medicare Advantage Plans

While SSDI recipients under 65 may have fewer Medicare Advantage plans available to them, turning 65 gives them access to more Medicare Advantage plans, often with enhanced benefits.

Lower Medicare Supplement Premiums

Medicare Supplement premiums for beneficiaries under 65 can be significantly higher due to their disability status. However, when they turn 65, they are eligible to enroll in a Medigap plan with standard premium rates.

Opportunity to Switch Plans:

SSDI beneficiaries who initially enrolled in a Medicare Advantage or Medicare Part D plan may find better options available at 65 that meet their healthcare needs or offer lower costs.

Employer or Retiree Coverage

Some SSDI recipients become eligible for employer-sponsored retiree health benefits at 65. If this is the case, they should evaluate how this coverage works with Medicare and whether they need any additional Medigap or Medicare Advantage coverage.

Learn more about Medicare and employer coverage

Prescription Drug Coverage

At 65, beneficiaries may have access to new Part D prescription drug plans that offer better coverage for their specific needs. Turning 65 is a great time to review all options and switch plans if needed. Please note; coverage changes each year and the Annual Enrollment Period is an important time to make necessary changes.

Agents watch a quick video on Sunfire and Connecture enrollment platforms

Medicare provides critical healthcare for SSDI recipients before age 65, but the process of aging into Medicare benefits requires careful planning. Understanding Medicare enrollment timelines, coverage options, and the opportunities available upon turning 65 can help SSDI beneficiaries maximize their benefits and avoid coverage gaps. Consulting a licensed Medicare agent can help ensure the best plan choices based on individual health needs and financial considerations.

Medicare Advantage (MA) plans are growing in popluarity as an alternative to Original Medicare, often attracting enrollees with low premiums, extra benefits, and all-in-one coverage. However, understanding the true Medicare Advantage Plan cost breakdown is crucial to avoid unexpected financial burdens. Here’s a detailed look at the key expenses associated with Medicare Advantage plans.

Premiums

Many MA plans advertise low or even zero-dollar premiums. However, enrollees must still pay the standard Medicare Part B premium ($185 per month in 2025) unless they qualify for financial assistance. Some plans may also charge an additional monthly amount for extra benefits, like dental comprehensive coverage.

Deductibles and Copays

Unlike Original Medicare, which has standardized costs, Medicare Advantage plans vary widely in deductibles and copay amounts. Enrollees of some MA plans must to meet an annual deductible before coverage kicks in, and they charge copays for doctor visits, hospital stays, and prescription drugs.

Out-of-Pocket Maximums

One advantage of MA plans is that they have an annual out-of-pocket maximum, unlike Original Medicare. In 2025, the maximum amount a MA plan CMS allows MA plans to charge for in-network services is $9,350. Please keep in mind, not all plans charge this amount for an out-of-pocket maximum; most plans have lower MOOPs. This is the most they are allowed to charge, the amount varies greatly by plan. Once this limit is reached, the plan covers all additional costs for the remainder of the year.

Out-of-Network Care

Most MA plans operate within a provider network. HMO plans require enrollees to use only in-network providers, while PPO plans allow some out-of-network visits at a higher rate. Please note; unless you are in a emergency situation, seeking care outside the network can lead to significant additional expenses.

Prescription Drug Costs

Many Medicare Advantage plans include Part D prescription drug coverage. The cost for prescrptions vary based on the plan’s formulary. Factors such as tiered formulary pricing and preferred pharmacy networks can influence out-of-pocket expenses for medications. Most plans also have a prescription deductible to meet for medications over a specific tier level.

Hospitalization and Specialist Care

While MA plans cover hospital and specialist care, costs can add up quickly. Some plans charge daily copays for hospital stays. Additionally, specialist visits usually have higher copays than PCP visits or require referrals, adding another charge.

Extra Benefits and Hidden Costs

Medicare Advantage plans often include extra benefits like dental, vision, and hearing coverage. However, these benefits may have limitations, such as caps on coverage or a restricted provider network, which can lead to unexpected out-of-pocket expenses.

Travel and Emergency Care Costs

Unlike Original Medicare, which offers nationwide coverage, most MA plans have geographic restrictions. If you travel frequently, you may face higher costs for out-of-network emergency care or require a plan with national coverage options.

Agents see how easy it is to compare MA plans with Sunfire and Connecture

Medicare Advantage plans can be a cost-effective option for some enrollees, but it’s essential to understand the full financial picture. By carefully reviewing plan details, including premiums, out-of-pocket limits, network restrictions, and prescription drug costs, enrollees can make informed decisions about healthcare coverage and avoid expensive surprises.

Need a scope; click here

There have been some important Medicare SEP changes in 2025 that both agents and enrollees need to be aware of. These regulations were put into effect by the CMS. We will explain those changes and how to navigate them. We’ve summarized the changes and how they could impact your clients.

SEPs for D-SNPs & LIS enrollees

As of January 1, 2025 CMS eliminated the quarterly SEP that let dual eligible individuals or those with LIS make MA/MAPD Medicare Advantage plan changes once each quarter during the first 3 quarters.

What replaced the quarterly SEP for D-SNP & LIS enrollees

Instead of a quarterly SEP, CMS has provided a monthly SEP (Code DEP). This allows DSNP and LIS beneficiaries to disenroll from their MAPD plan and enroll in Original Medicare and a standalone PDP. The SEP also allows LIS members to switch their current PDP coverage to another PDP plan.

There is also a monthly integrated SEP (INT-SEP). This SEP allows only full dual eligible beneficiaries to switch to or from one integrated D-SNP with aligned Medicaid plan to another.

Monthly INT SEP details

Full Dual Beneficiaries can use the INT-SEP once per month. The effective date of the new plan will be the first day of the following month.

Plans that are eligible for the INT-SEP include:

• FIDE SNP: Fully Integrated Dual Eligible Special Needs Plan
• HIDE SNP: Highly Integrated Dual Eligible Special Needs Plan
• AIP: D-SNP is an Applicable Integrated Plan 

Although dual eligible plan enrollees can change plans monthly, staying in their current plan allows them to avoid disruptions to their coordinated care plan.

Disaster (DST) SEPs

CMS has also changed the SEP (DST-SEP). The DST SEP is for those affected by an event that results in a government declared disaster or other emergency. The election process will change as of April 1, 2025.

Medicare beneficiaries who miss a valid election period due to a government declared disaster or emergency must follow these guide lines:

Beneficiaries who qualify for the DST SEP must submit applications directly through CMS by calling 1-800-MEDICARE or TTY 1-877-486-2048 to submit an application.

In other words, CMS will not accept broker assisted DST applications.

Despite the changes to these SEPs, full and partial dual eligible beneficiaries can continue to use other SEPs, if they are eligible (AEP, OEP, move, loss/gain of eligibility, etc.).

Residents of CT and Medicare agents who offer plans in CT need to be aware of the changes to the CT MSP income limits 2025. The MSP program provides assistance to beneficiaries with limited incomes to help cover their medical costs. Understanding the CT MSP income limits is extremely important for anyone on Medicare and has a limited income. Especially if they depend on financial assistance to access needed healthcare.

What is MSP (Medicare Savings Program)

MSP stands for The Medicare Savings Program. Each state administers this program and provides assistance with medical costs for individuals on Medicare with limited income and resources. It helps pay Medicare premiums, deductibles, coinsurance, and copays.

To participate in the program, you must be eligible for Medicare Part A (hospital insurance) and meet income and asset criteria. In the state of CT, DSS administers the Medicare Savings Program.

CT MSP Income Limits 2025

The MSP in CT provides 3 different levels of help. Each level has a separate income limit that qualifies beneficiaries. Please note; the income limit is adjusted based on household size.

The 2025 income limits for each level of MSP are listed below:

Qualified Medicare Beneficiary (QMB)

Those who qualify for the QMB level recieve the highest level of help.  Individuals who qualify for this program, have income of up to 100% of the FPL (Federal Poverty Level).  The QMB program pays the Part B Medicare premium, deductibles, coinsurance, and copays.

Individuals with a monthly income of $2,752 for an individual and $3,719 for a couple qualify as QMBs.

Learn about medicare Extra Help

Specified Low-Income Medicare Beneficiary (SLMB)

The SLMB level pays for the Medicare Part B premiums and does not cover deductibles or coinsurnae payments.

Individuals who have an income level of $3,013 per month for an individual or $4,072 a month for a couple. In other words, individuals must have an income level between 100% and 120% of the FPL.

Additional Low-Income Medicare Beneficiary (ALMB)

The ALMB is similar to the SLMB program; it pays the Medicare Part B premium only. It does not cover deductibles or coinsurance payments. It is availabel to those who have income between 120% and 135% of the FPL.

To qualify for this level of help; indivduals must have monthly income of $3,209 for single or $4,336 for a couple.

Please note: This program is subject to available funds and is issued on a first come first served basis

How to Apply for CT MSP

Those who want to apply for CT’s MSP program can do so through the Department of Social Services (DSS).

Individuals must complete a CT state (W-1QMB) application form. There are a few different ways to complete and return the form;  online, through the mail, or in-person at a local DSS Regional Office.  

Beneficiaries must provide information such as: Medicare enrollment status, income, assets, and other relevant information. DSS provides help with the application for anyone who needs it. Beneficiaries can also have an authorized person complete the application if needed.

Click here for a list of local DSS offices.

To apply online, visit www.connect.ct.gov, click on the ‘Apply for Benefits’ tab and apply as directed.

Those who wish to apply for MSP only; download and complete application below:

Medicare Savings Program Application (W-1QMB)

Formulario de Renovación de programas de ahorro de Medicare (W-1QMBS)

To apply for other assitance programs as well as the MSP program: SNAP (food stamps), Medicaid for Employees with Disabilities (MED-Connect), Medicaid for the Aged/Blind/Disabled (HUSKY C), and/or cash assistance, download the application below.

Click here to apply for Husky C and or Cash assistance program benefits

Haga clic aqui para Husky o asistencia en efective CW-1ES Solicitud de Beneficios

The CT MSP program provides an essential service to qualified individuals. It provides financial assistance to cover Medicare costs.

Agents who want to be part of the team at Crowe – click here for onine contract

Watch a YouTube video and learn about changes for Dual, Partial Dual and LIS SEP changes

For additional information on how to apply, please visit www.ct.gov/dss/apply.

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.

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 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.

If you’re a Medicare beneficiary with higher income, you may be subject to the Income-Related Monthly Adjustment Amount (IRMAA) for your Medicare Part B and Part D premiums. However, if your income has recently decreased due to qualifying life events, you may be eligible to appeal the IRMAA determination. Here’s what you need to know about how to appeal an IRMAA.

What is an IRMAA

The Medicare Income-Related Monthly Adjustment Amount (IRMAA) is an extra charge added to Medicare Part B and Part D premiums if the beneficiary’s income exceeds certain thresholds. The Social Security Administration (SSA) determines IRMAAs based on the tax return from two years prior. In other words, a 2025 IRMAA is based on 2023 income.

IRMAA brackets 2025

When you can appeal an IRMAA

Medicare beneficiaries may appeal an IRMAA redetermination if they experience a significant life-changing event that cause a reduction in income. Qualifying events include:

1. Marriage, divorce, or annulment
2. Death of a spouse
3. Retirement or reduction of working hours
4. Loss of a pension or settlement of an employers pension plan
5. Loss of income-producing property due to a disaster or other circumstance

Any of these situations may cause a decrease in income. This provides grounds for an appeal.

How to File an IRMAA Appeal

To file an appeal, beneficiaries must complete Form SSA-44, Medicare Income-Related Monthly Adjustment Amount – Life-Changing Event. Here’s how to do it:

1. Download the Form – Obtain Form SSA-44 from the Social Security website or by at the local Social Security office.
2. Complete the Form – Provide details about the life-changing event, including supporting documentation (such as a marriage certificate, employer statements, or tax returns).
3. Submit the Form – Either mail or deliver the completed form and supporting documents to the local Social Security office.
4. Await a Decision – SSA will review the request and notify the beneficiary of the outcome. If they deny the appeal, the beneficiary may request a further review.

To Sum it up

If your income changes due to a qualifying event, don’t hesitate to appeal an IRMAA determination. Many beneficiaries successfully lower their Medicare premiums through this process. Be sure to gather all necessary documentation and submit the appeal as soon as possible to avoid overpaying.

For more details, visit the official Social Security Administration website or contact your local SSA office.