Medigap - Medicare Supplement
- Helps fill "gaps" in Original Medicare.
- Helps pay some of the remaining health care costs and supplies not covered that Original Medicare:
Medicare will pay its share of the Medicare-approved amount for covered health care costs, then, your Medigap pays its share.
What you need to know about Medigap plans
- You must be enrolled in Medicare Part A & B.
- Medigap is NOT a Medicare Advantage. You CAN’T enroll in both.
- You pay a separate monthly premium for a Medigap plan.
- Guaranteed renewable is a feature of Medigap.
- Medigap policies do not include prescription drug coverage. You need to enroll into a separate Medicare Prescription Drug plan (Part D)
- It is illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage plan unless you are switching back to Original Medicare.
- Medigap policies do not cover long-term care, vision, or dental care, hearing aids, eyeglasses, or private-duty nursing.
Medicare Part D
- Covers a wide range of prescription drugs
- Has a list of covered drugs (formulary).
- Places drugs into “tiers” have a different cost per tier. For example, a drug in a lower tier will cost you less than a drug in a higher tier.
- Tier 1—lowest copay: most generic prescriptions
- Tier 2—medium copay: preferred, brand-name
- Tier 3—high copay: brand-name prescription drugs
- Tier 4—higher copay: non-preferred, brand-name
- Tier 5—highest copay: Specialty tier highest cost prescription drugs
Formulary Exception Rules
Medicare drug plans may have these coverage rules
- Opioid pain medication safety checks
- Prior Authorization
- Quantity limits
- Step therapy
- Part D vaccine coverage
- Drugs you get in hospital outpatient settings
Formulary Exception requests are common among Medicare Beneficiaries. The request is best handled by your prescribing doctor.
Your doctor feels you need a higher Tier drug instead of a similar lower Tier drug, your doctor may ask your plan for a Formulary Exception or Tier reduction to lower your co-pay may also come into play.