Medicare Part D

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• Why agents can not assist with stand-alone Part D plans like before? →

  Most Part D Plans ceased contracting agents to assist with stand-alone Part D enrollments.
  
  Agents are still able to assist with enrollments in Medicare Advantage Plans and Medigap Plans (Plan F, Plan G, Plan N, etc.) through your agent it enables us to be compensated and continue supporting you as your agent of record.
  

• Shop Medicare Advantage Plans with Shawn Marie →

  If you are enrolling in an Advantage Plan or Medigap/Medicare Supplement Insurance Plan (Plan G, Plan N, Plan F, etc.), please consider submitting your application through me, not Medicare.gov like folks have to do for stand-alone Part D.
  
  If you call the number on the back of your Advantage Plan card to change with the same insurance company, our services continue!

  • If your plan renews next year and you want to keep it, you don’t need to do anything—it will renew automatically unless discontinued.

  • Approved enrollment from a Part D or Medicare Advantage plan to a Part D or Medicare Advatage Plan automatically cancels your old one.

  • No single “best” plan exists. You make the best decision you can with the information available.

• Shop Stand-alone Part D Plans on Medicare.gov →

  Medicare.gov lets you compare prices at different pharmacy chains, and every plan also offers a preferred mail-order option.
  
  🔹 Medicare.gov
  🔹 Call 1-800-MEDICARE
  ‍ ‍ TTY Number: 1-877-486-2048

  🔹 SHIPHELP.org

  🔹 Contact insurance companies directly.

• Do I need to cancel the Part D or Advantage Plan I am replacing? →

  • Enrollment in a new Medicare Advantage or stand-alone Part D Plan automatically cancels the Advantage Plan or Part D plan you had before once approved by Centers for Medicare & Medicaid Services for the requested effective date.

  • Medigap Plans do not cancel automatically and require the member to call the number on the back of the Medicare Supplement Insurance card to cancel).

• What if my Advantage Plan is discontinued next year? →

  If your Advantage Plan is discontinued next year, enroll in a new Advantage plan or a Medigap and Part D Plan by 12/31 to avoid any gap in coverage. Your Special Election Period usually extends through the end of February, but check your letter from the insurance company for your exact deadline.

• What if my Advantage Plan pr Part D Plan is available next year and I want to keep it? →

  If your Advantage Plan or stand-alone Part D plan renews next year and you want to keep it, you don’t need to do anything. It will renew automatically.

  Medigaps are not annual contracts as they are standardized plans that cover your out of pocket costs according to the letter you are enrolled in. As long as you pay your premiums, coverage continues.

• Enrollment Periods when changing existing Advantage or Part D →

  Annual/Open Enrollment PeriodOctober 15th - December 7th
  Approved applications take effect January 1st.

  • Enroll in a Medicare Advantage Plan

  • Enroll in a Part D Prescription Drug Plan

  • Return to Original Medicare

  Let's secure a Medigap to cover costs before leaving an Advantage Plan for Original Medicare.

  Discontinued Plan (Two Enrollment Windows)
  AEP: October 15th - December 7th and

  SEP: October 15th - February 28th

  Medicare Advantage Open Enrollment Period January 1st - March 31st

  Approved changes take effect the 1st of the month following application.

  • Switch Advantage Plan to Advantage Plan.

  • Return to Original Medicare from an Advantage Plan.

  Let's secure a Medigap to cover costs before leaving an Advantage Plan for Original Medicare.

  Special Enrollment Period (SEP) Varies.

  Some examples

  • Plan discontinuation/termination.

  • Moving out of the plan's service area.

  • Change in Financial aid status (Low Income Subsidy/Extra Help, Medicare Savings Program/Medicaid.

  Enroll in a chronic conditions plan.

  Annual/Open Enrollment PeriodOctober 15th - December 7th
  Approved applications take effect January 1st.

  • Enroll in a Medicare Advantage Plan

  • Enroll in a Part D Prescription Drug Plan

  • Return to Original Medicare

  Let's secure a Medigap to cover costs before leaving an Advantage Plan for Original Medicare.

  Discontinued Plan (Two Enrollment Windows)
  AEP: October 15th - December 7th and

  SEP: October 15th - February 28th

  Medicare Advantage Open Enrollment Period January 1st - March 31st

  Approved changes take effect the 1st of the month following application.

  • Switch Advantage Plan to Advantage Plan.

  • Return to Original Medicare from an Advantage Plan.

  Let's secure a Medigap to cover costs before leaving an Advantage Plan for Original Medicare.

  Special Enrollment Period (SEP) Varies.

  Some examples

  • Plan discontinuation/termination.

  • Moving out of the plan's service area.

  • Change in Financial aid status (Low Income Subsidy/Extra Help, Medicare Savings Program/Medicaid.

  Enroll in a chronic conditions plan.

• Verify your medications are covered next year and what rules may apply. Do not assume a plan that worked for you this year will work the same next year. →

  Verify your medications are covered next year and what rules may apply.

  1. Are your medications in the plan’s formulary (list of medications)?

  2. Check tier, prior authorization (PA), step therapy (ST), and quantity limits (QL).

  3. Explore pricing using different brands of retail pharmacies and a plan’s preferred mail-order.

  4. Review how these costs apply before you reach the calendar year cap for covered medications ($2,100 in 2026).

  5. Add plan premiums and costs for covered medications at the pharmacy for total estimated cost of medications on the plan.

  6. All plans offer the Medicare Prescription Payment Plan (M3P) that allows you to spread out payments through the remainder of the year.

• Verify the pharmacies you can use? →

  Per Medicare.gov you can choose where to fill your prescriptions, but using certain types of pharmacies might save you money. Some pharmacies may offer a 2- or 3-month supply of covered drugs.

  🔹 In-network

  🔹 Preferred in-network

  🔹 Mail-order

  🔹 Out-of-network pharmacies

• What if I don't take any expensive medications? →

  Explore adding an expensive medication to the plan.
  
  Don’t know of any? Do a search for some expensive medications then add them to your search to see how the plan searches vary.

• What if I’m taking a drug that isn’t on my plan’s drug list when my drug coverage begins? →

  Per Medicare.gov

  • Work with your prescriber time to find another drug on the plan’s formulary that works for you.

  • The yearly cap only applies to medications covered by the plan providing Part D coverage.

  When You Can Ask for an Exception?
  You or your prescriber may request an exception if:

  • You already tried similar drugs on the plan’s formulary and they didn’t work for you.

  • Your prescriber believes you need a specific drug because of your medical condition.

  • Your prescriber believes a coverage rule should be waived (such as a quantity limit, prior authorization, or step therapy).

  What Happens After You Request an Exception

  • If the plan agrees, they will cover the drug.

  • If the plan denies your request, you have the right to appeal the decision.

  • Rules may differ for people who move into or already live in a facility (like a nursing home or long-term care hospital).

• How can two people pay such different prices for the same medication at the same pharmacy? →

  Tiering varies by plan. Even if a drug is expensive, each Medicare Part D plan sets its own tiers.

  • One plan may put a drug in Tier 3 (preferred brand)

  • Another may put it in Tier 4 (non-preferred)

  • Another may classify it as specialty tier

  Deductibles, copayments and coinsurance are plan-specific and also impact how two people taking the same medication might have very different out-of-pocket costs depending on their plan.

• What are Utilization Controls and how do they apply? →

  Medicare drug plans may have rules that determine if and how the Part D or MAPD may cover drugs. These rules can be called:
  
  🔹Prior Authorization
  Your doctor must get approval from the plan before the plan will cover the medication. Used a lot for: expensive drugs, specialty drugs, or medications with safety risks.

  🔹Step Therapy
  You must first try a lower-cost or preferred medication before the plan will cover a more expensive version.

  🔹Quantity Limits
  The plan limits how much of the drug you can get at one time (e.g., 30 pills per 30 days).

  🔹Medication safety checks, drug management programs. Plans check for:
  Dangerous drug interactions
  Opioid safety
  Duplicate medications
  High-risk prescribing
  These are automatic safety systems.
  
  Quote systems, plan documents such as plan formularies (lists of medications) outline some of these controls.