Medigap aka Medicare Supplement

  • Helps fill "gaps" in Original Medicare.
  • help pay some of the remaining health care costs and supplies not covered that Original Medicare such as:
    • Copayments
    • Coinsurance
    • Deductibles

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

  1. You must be enrolled in Medicare Part A & B .
  2. Medigap is NOT the same as Medicare Advantage.
    • You CAN NOT be enrolled in both at the same time.
  3. You pay a separate monthly premium for a Medigap plan.
  4. Any standardized Medigap policy is guaranteed renewable even if you have health problems. You cannot cancelled as long as you pay the premium.
  5. Medigap policies aren't allowed to include prescription drug coverage. You need to enroll into a separate Medicare Prescription Drug plan (Part D)
  6. It is illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage plan, unless you're switching back to Original Medicare.
  7. Medigap policies generally don't 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) specific to the plan. 
  • 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 
Note:
Starting January 1, 2021, if you take insulin, you may be able to get Medicare drug coverage that offers savings on your insulin. You could pay no more than $35 for a 30-day supply. 

 

Formulary Exception Rules:

Medicare drug plans may have these coverage rules:  

If you or your doctor believe that one of these coverage rules should be waived, you can ask your plan for an Exception. 

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.