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Part D

Part D and How it Works


Part D is voluntary prescription drug coverage that pays for medications that beneficiaries would normally pay for themselves, lowering the price for retail medications and making them more affordable. It is a Federal program that was started in 2006. However, private insurance companies are the ones that provide the coverage.

To limit their exposure, these companies use formularies, enrollment periods and coinsurance to pass some of the risks on to the insured. Rarely, is there ever a time where any one medication is covered at 100%.

Because it was designed to cover most medications, the laws in place are there to protect both the insured and the insurance company. When shopping for coverage, you use your current prescriptions to determine which company provides the most coverage.

When To Enroll

There are certain enrollment periods to be aware of that affect your ability to enroll. Knowing these periods is crucial in avoiding any late enrollment penalties when going on Medicare for the first time.

Open Enrollment.

You are first able to get a Part D plan when you are new to Medicare.

Open Enrollment starts 3 months before you turn 65, the month you are 65 and 3 months after your turn 65. The effective date can be the same day Part B goes into effect.

You can delay your coverage for 3 months after your birth month to avoid a late enrollment penalty. If you do not have any other drug coverage, be mindful not wait too long to enroll.

Special Election period.

If you are working beyond the age of 65, you will have a special window to enroll into Part D. You can make the effective date the date your Part B goes into effect and are able to enroll 60 days prior but no later than 60 days after your coverage ends.

If you miss your SEP, you will have to wait until the next Annual Election Period before you are eligible to enroll and may be penalized for having a lapse in coverage.

For Example:

Bob is a mechanical engineer and loves what he does. His wife is a few years younger and he decides he wants to work until he is 68. This way, he maintains coverage on his wife until she is eligible for Medicare.

Two months before retiring, he walks into his local Social Security office and enrolls into Medicare Parts A and B. His start date is set for May 1st.

Bob does not take any medications and decides he wants to delay enrolling into Part D as long as possible. After learning about the late enrollment penalty, he makes the effective date July 1st.

Since he was within the 60-day window, he avoids any late enrollment penalties.

Annual Election Period.

The Annual Election Period is the time of the year where people can make changes to Part D drug plans.

October 15th – December 7th is the time where you can enroll, disenroll, shop benefits and compare prices. Any changes you make, become effective January 1st the following year.

This is when companies make changes to their formularies and benefits. They change their networks, their copays, deductibles, coinsurance.

With all of these changes going on, it is critical you shop your plan every year. This way you are not affected and you keep your out-of-pocket as low as possible.

Even if you like the plan that you are on now, shopping your benefits will determine if there is a better plan that may be available.

AEP also allows you to shop your Medicare Advantage Plan, but we will talk more about that in a different article.


In order to be eligible for Part D, you have to be enrolled into at least Part A. Regardless if you are on Medicare disability or over the age of 65, as long as you have Part A, you are eligible to enroll into Part D.

People who continue to work when they are first eligible and have some kind of credible drug coverage through an employer, typically postpone their Part D enrollment. If your current coverage does NOT offer drug benefits, you may want to consider finding a plan to avoid any penalties.

Delaying Enrollment:

Although Part D is “Optional,” use caution when delaying enrollment. If you decide not to apply, and have no other coverage, you will have a late enrollment penalty.

Even if you are not taking any medications, it may be a good idea to shop for a plan.

Late Enrollment Penalty:

The Part D late enrollment penalty is a fine that you pay for not having any credible drug coverage when you are eligible for Medicare.

The penalty is 1% per month for every month you do not have coverage of the average monthly premium. Since the average monthly premium changes, it is hard to determine exactly what that penalty may be.

The fine is then added to your monthly premium when you finally do enroll. You will continue to pay the penalty for as long as you continue to have a Part D drug plan.

For Example:

Greg is a retired game warden who spent his entire carrier outdoors. He is 68 years old, in very good health and does not take any medications. He thought it would save him money to not have to apply for a drug plan and he determined he will apply when he really needs one.

After learning about a late enrollment penalty, he decided it was time that he applies for coverage.

He has to wait to enroll during the Annual Election Period and his coverage would take effect January 1st.

Let’s say the average monthly premium was $30 per month for that time period. He was without coverage for 38 months. At 1% per month, his penalty is an extra 38% or $11.40. He would pay this penalty for as long as he has part D coverage.

Average Monthly Premium X 1%/Month = Penalty

$30 X 1%(38months) = $11.40

How to pick a plan:

There are several different ways to pick a Part D drug plan. The premium, deductible, coinsurance, copays, and Star ratings are all different between the plans and change every year.

The best way to choose a plan is based on the total out of pocket for the year. This includes all of your premium, deductible and copays.

Medicare.gov has a great tool that most insurance agents refer to when comparing plans.

First, we get a list of all of your medications, your dosages, how often you take them and your preferred pharmacy. We then get a list of all the best-recommended plans based on this information. We would compare these plans from the lowest to the highest out of pocket and the plan’s star rating.

Usually, you would pick the plan with the lowest out of pocket.

For Example:

Mrs. Suzie was recently diagnosed with type 2 diabetes. In addition to her cholesterol medication, she was prescribed metformin to help control her sugar.

When shopping for a plan, she entered her 2 medications and preferred pharmacy. The system listed 15 plans starting with the lowest out of pocket to the most expensive.

Here were her top 3 choices in her area, based on the medications she takes.

Remember, this is just an example. Your results may be different.

Based on her situation, Medicare recommends the first plan because it has the lowest out of pocket for the year. Although the second option has about the same premium, the first option costs less, even though the deductible is higher.

How Plans are measured:

Looking at the chart above, you will notice several columns to compare when picking a plan.

Estimated Annual Drug Costs.

This is the total estimated out-of-pocket for the year the medications that are covered. It includes all of the categories below to give an estimate. This is what most people compare when selecting a plan.

Monthly Premium.

This is how much each plan would cost. You can pay for it by having it taken out of your social security deposit, setting up a bank draft, or having a bill mailed directly to you.

Deductible and Drug Copay/Coinsurance.

This is what your responsibility is when paying for your medications. It is determined based on each company’s formulary and changes between companies.

The deductible is what you pay before coverage starts.

The copay is what your portion is at the pharmacy when buying the drugs.

Sometimes, instead of a copay, you would pay a percentage of the medication depending on the ‘tier’ it falls in, known as the coinsurance.

Drug Coverage, Drug Restrictions, and Other Programs.

This section tells you if all of your medications are covered by the plan. You can click in this section to see if a drug is covered and what tier it falls within.

If a Medication has restrictions, this section will specify what medication has what restrictions. Usually, it will tell you that you cannot get but a certain amount each month, for control purposes.

Other Programs allow you to apply for extra help with your out of pocket if you have a low-income situation.

Donut Hole.

Starting in 2019 The Donut Hole, also known as the Part D coverage gap will start once the cost of your medications reaches $3820. This is the total cost between what the company paid and what you paid – However that may be split.

Once you reach the donut hole, you are responsible for the next $5,100.

To be clear, this $5100 is not 100% your responsibility and there is some help available.

While in the donut hole, pharmaceutical companies will be on the hook for a portion of your bill.

Starting in 2019 pharmaceutical companies will be responsible for 63% of the cost of generic medications and 75% of the name brand.

Leaving you responsible 37% on generic and 25% on the brand.

After you reach $5,100, you will enter what is known Catastrophic Coverage.

For Example.

To make this as clear as possible, let’s say the retail cost of your medications is $6,000 for the year.

Once all of your copays and deductibles, plus what the insurance company paid reaches $3820, you will fall in the coverage gap known as the donut hole.

Your copays were $1,000.

The insurance company paid $2,820 before you reached the coverage gap.

At this point, you are responsible for the next $2,180 to total the cost of your Medications but only at 25% (assuming they were name brand).

$6,000 (RETAIL) – $3,820(TOTAL PAID SO FAR) = $2,180 (COVERAGE GAP)

In the donut hole, you pay 25% of $2,180 or $545 (Assuming they were named brand drugs).

Out of the $6,000, you paid $1,545

$1.000 (COPAYS AND DEDUCTIBLE) + $545 (25% of retail in the donut hole)

Simple right?

Catastrophic coverage.

This is what is beyond the donut hole. Once you reach the out of pocket limit in the donut hole of $5,100, you will reach what is known as Catastrophic Coverage.

Catastrophic coverage starts after you have paid all of your $5,100 out of pocket.

At this point, your plan picks up 95% of the cost your medications.

We are here to help.

Medicare Part D can be overwhelming. If you are still confused about the different coverage limits and plan benefits, we are here when you need it.

We offer free Part D help for anyone who is looking to shop their current plan.

Every company makes changes to all of their benefits each year. This is why Medicare recommends you shop your plan every single year. Even if you like your current benefits, they may be completely different next year.

We provide unbiased help to anyone who needs it. Our job is to make sure you are maximizing your benefits.

Regardless if you are new to Medicare or been on Medicare for a while, we at the Benefit Enrollment Center are here to help. Our direct phone number is: 1-800-729-9590.


What is Medicare Part B

Part B is Outpatient Medical Insurance

Part B is a part of Original Medicare. It covers outpatient medical expenses such as doctor’s visits, preventative care, lab work, X-rays, tests, CAT scans, MRIs, etc. It covers about 80% of most approved outpatient medical expenses after meeting a small deductible. 

There are a few things to consider before signing up for Part B. Depending on the situation, you may be need to delay your Part B enrollment. Keeping your group benefits in place because you choose to continue working beyond the age of 65 may be a good idea.

The size of your company’s group and the type of coverage you have effect your options. Going on Medicare for the first time, there are a lot of things to look over. Having all the correct information can save thousands of dollars in premium.

Let’s use Jan as an example to see how Part B works.

Jan loves the outdoors. Spends a lot of her time gardening, taking walks on the trails behind her house. She spends a lot of time with her grandchildren where they enjoy the playground she had built for them.

One chilly morning she steps out on her front porch and ends up slipping on a layer of ice that had accumulated on her steps the night before. A visit to urgent care and knee surgery left her worried about her medical bills.

Thankfully she had a full recovery and with the help of Part B and her secondary Medicare Supplement coverage all of her outpatient services were covered and her out-of-pocket was minimal.

A Few Things About Part B

80% Coverage

After a small deductible, Part B covers about 80% of approved, outpatient, medical services by participating providers that accept Medicare.

The deductible changes slightly every year.

See Medicare’s website to determine what your cost is for this year. 

Without some kind of secondary coverage like a Medicare Supplement, the 20% can add up quickly.

Lets say someone ends up having a routine colonoscopy. The only coverage they have is traditional Medicare Parts A and B.

Assuming that Medicare approved the procedure, 20% would be the patient’s responsibility after they have met their Part B Deductible. Without Medigap coverage, they would pay the entire 20% themselves.

According to Healthcarebluebook.com, “..it is not uncommon to find colonoscopy pricing below $1000 or above $3000.” Someone can find themselves owing more than $600 for something very routine.

With the rising costs of healthcare there is no telling what someone would end up owing. Even on something as simple as a routine procedure.

To find out if a provider accepts Original Medicare, simply call their office and ask. There is a surprisingly small amount of providers that do NOT accept Traditional Medicare.


Some are automatic.

At the age of 65 if you are on Social Security you will be automatically enrolled. If you plan to continue working past the age of 65, then you will have the option to delay your Part B enrollment in favor of a credible group plan under an employer.

Remember to send in the appropriate forms if choosing to delay. Usually, these forms come with your Medicare Card so be sure to not throw them away!

You may have to enroll yourself.

When you turn 65, you will not be automatically enrolled in Part B if you are NOT drawing Social Security benefits. If Part B was delayed for any reason, whether you decided to work or continued to have benefits through a spouse, you may need to personally enrolled yourself when the coverage you opted for runs out to avoid any late enrollment penalties. Consider applying for Part B within 60 days from the time your existing coverage is set to expire.

Enroll by:
  • Going online to the Social Security website here.
  • Walking in to a local Social Security office without an appointment.
  • Making an appointment with an agent at a local Social Security office.
  • Calling your Social Security office and enroll over the phone (They will send you the necessary paperwork to fill out)

Part B has a monthly premium.

Unlike Part A (for most people), Part B will include a monthly premium that you will need to pay. While the actual amount will differ depending on your income bracket from two years ago.

For example: If coverage is set to start next year you would look at your gross adjusted income for determine what your Part B premium is going to be. If you are married, you would include the income of your spouse as well.

There are programs in place to help you with your Part B premiums. Be sure to check with your state’s Medicaid office to see what kind of programs they have available. Each state has their own specific requirements. Contact them to determine what kind of programs may be available


2018 Part B Price Chart

The chart below outlines how much Part B costs.

If your yearly income in 2016 (for what you pay in 2018) was You pay each month (in 2018)
File individual tax return File joint tax return File married & separate tax return
$85,000 or less $170,000 or less $85,000 or less $135.50
above $85,000 up to $107,000 above $170,000 up to $214,000 Not applicable $189.60
above $107,000 up to $133,500 above $214,000 up to $267,000 Not applicable $270.90
above $133,500 up to $160,000 above $267,000 up to $320,000 Not applicable $352.20
above $160,000 above $320,000 above $85,000 $433.40

There may be a penalty if you choose to not enroll or delay your enrollment.

That depends if you have credible coverage at the time you are first eligible. Having no other coverage, or having coverage that may not considered credible, you WILL have a late enrollment penalty.

For every 12 months that Part B is delayed, the penalty will be 10% of the monthly premium added to the standard monthly premium. So, if it is originally $134 and then a penalty is applied, the new premium will higher. The amount will depend on how long the enrollment was delayed. The penalty will stay for as long as you continue to stay on Medicare.

A couple examples:

Delaying Part B with no other coverage:

George, who is 66, is very healthy. He never goes to the doctor and does not take any Medications. Exercises regularly, has great eating habits and has a very active lifestyle. Retiring when he was 60, George, works part time at the local pet store. Being part time, he does not qualify for health insurance. He is did not apply for Part B against the recommendation of his financial advisor.

Whenever George enrolls into Part B, he will be subject to a late enrollment penalty which will add an additional 10% on top of his Part B premium for every year he is without coverage whenever he finally does decide to enroll. If he waits until he is 70, he will pay an extra 50% on top of his regular monthly premium.

Continuing to Work

Frank is turning 65 this year and works for a large automobile company. He decided to delay Social Security and will continue to work until he reached full retirement age at 66. He also postponed his Part B enrollment because the company he works for provides his health benefits and he decided he will continue to keep this coverage until he retires at 66.

Since Frank has credible coverage through his employer, delaying his Part B premium will not only save him money, he will also not have to pay a penalty because he has had continuous, credible, coverage while he continued to work.

Delaying Part B with COBRA

Lisa, like Frank chose to work till retirement age of 66. Before she turned 65 the company decided to downsize and do away with her position forcing her to take an early retirement. Her benefits coordinator said that she is eligible to pay for COBRA and continue her benefits for 18 more months.

Thankfully, Lisa spoke to a licensed agent that advised her to have caution when taking COBRA and delaying her Part B enrollment. Since COBRA is not considered credible coverage, she would be subject to late enrollment penalty. She ended up enrolling into Part B at 65 and choosing a Medigap policy and avoided the frustration of having a penalty.

Credible coverage and why it’s important.

If your employer has 19 or less employees on your group benefits, then that coverage is not seen as credible and you should consider enrolling in Part B during your Initial Enrollment Period in order to avoid a late penalty being added to your monthly premium when you do enroll.

Credible Coverage is coverage that offers comparable benefits to those you would be receiving under Medicare.  If you fall into this category of auto-enrollees, then you can expect to receive your insurance cards for Parts A and B in the mail around three months before your 65th birthday.

If you are eligible to remain on your employer plan after turning 65, then you will need to fill out a deferment form and sent it back to your local Social Security office.

Delay Part B in favor of group plans that cover 20 or more employees.  Not all employer or union health insurance plans are viewed as credible by the Social Security Administration.

Do not commit to any coverage options without knowing the full scope of the benefits that you have now. Ask your benefits coordinator if your coverage is considered “credible.” They’ll tell you if its a good idea to postpone.

Additionally, if you are retiring at 65 but delaying your Part B enrollment in favor of COBRA there is no COBRA policy that is currently considered to be credible coverage.

Delaying your Part B enrollment in favor this program like this will result in having an indefinite penalty being added to your monthly premium when you finally do enroll in Part B.

There is help around the corner

Turning 65 can mean finding too much Medicare information in your mailbox. Phone calls from strangers who are urging you to buy some plan that you know absolutely nothing about.

Not every person who claims to be an insurance agent will make the effort to explain each element of Medicare.

I want you to feel comfortable with your insurance coverage. I know how overwhelmingly confusing all of this information can be. That is why we are here to help.

Everyone needs proper health insurance, so why delay your Part B enrollment? Unless you are continuing to work past your 65th birthday and are under a group health plan, there is no reason to delay your Part B enrollment.

Unwarranted delays could lead you to have a late penalty fee added to your premium each month. You would actually be paying more for your coverage in the long run. 

I have seen firsthand the realities of having gaps in Medicare coverage.  My goal to make sure all seniors are informed of their Medicare options, and that they are 100% covered. Life can be unpredictable, but your Medicare does not need to be. 

If you would like more information on Medicare and Medicare Supplements, contact Christopher Westfall, Sr. at 1-800-729-9590.

Warning to Seniors on Medicare Regarding Scams

Seniors on Medicare are especially vulnerable to scammers and sometimes those doing the scamming are actually insurance agents trying to hide their identity.

Seniors can verify the identity of an insurance agent by getting the agent’s name, license number, and callback number and then verifying their license with the state’s department of insurance. The numbers for each state department of insurance can easily be found with this link. Contact your department of insurance before giving out any personal information to someone who has contacted you by phone.

Verify an Insurance Agent License

The good rule of thumb is – if they call you, you do not know who they are – regardless of what the CALLER ID says.
If you contact them, you are in control of who you are talking to. So, verify who they are, then call back their legitimate number

Here is the helpful video on the topic:

Christopher Westfall, National Producer # 596926

Medicare Supplement Plan N

Medicare Supplement Plan N can be a good value, depending on your location (ZIP code), Age, and whether you’re a male or female. Meaning, all rates and rate comparisons are personalized depending on YOUR situation.

For any agent to make a complete blanket statement that ONE particular plan is the best for everybody, all the time, is simply not aware of all of the options out there. I provide very personalized service by pulling up all available plans and all available companies for our potential clients. As always, my service is 100{57afd372ef552335ba870edf523b8e4a4ddf98dad7cf21c72091c800f1bfac05} Free.

Plan N Medicare Supplement can be a good value, or it might not, depending on your situation. To find out whether Plan N or Plan G or Plan F is the best for you, give us a call at 1-800-729-9590. It takes less than 3 minutes to give you the breakdown of what is available.

Working with someone else? At least get a second opinion (and more options) Call me today!

Aetna Medicare Supplement in the News

You might have seen it in the news…

Aetna was in the news this week about their pulling out of certain states in the “ObamaCare” exchanges.

This only impacts those UNDER 65 on regular health insurance, not your plan with Aetna.

This is a smart move for AETNA, as they’ve been losing money – like all insurers have, and Aetna has already lost over $400 million by participating in the “ObamaCare” exchanges.

Aetna’s Medicare plans are stronger than ever and are delivering the best value in the market right now with their below-average rate increases at renewal time. Part of the reason Aetna is able to deliver great renewals is because they recognize vulnerabilities, like the continued participation in the UNDER 65 health insurance market would continue to bring.

Thank you for allowing me and my office to help you with your Medicare Supplement plan.

Please remember that we are here to help if you have ANY questions at all about anything having to do with Medicare.


Christopher Westfall
Senior Savings Network

¿Cuál es el mejor plan de Medicare Supplement?

¿Cuál es el mejor plan de Medicare Supplement?

Si está considerando su primer plan de Suplemento de Medicare, o está considerando cambiar a un plan de Medicare Supplement más asequible, debe ver este video.

La mayoría de los agentes de seguros que trabajan con personas de la tercera edad presionarán a Plan F como la mejor solución. Mientras que el Plan F cubre todo, a menudo es a una prima tremenda, innecesaria. Los mismos beneficios exactos se pueden obtener con el Plan G, con el deducible pequeño, ahorrando así cientos al año. Pero, se pone mucho mejor.

Por favor, vea este video que explica los muchos beneficios del Plan G vs. Plan F:

¿Quieres ver las tarifas de TODOS los planes y todas las empresas? Podemos hacer eso, y mi servicio es 100{57afd372ef552335ba870edf523b8e4a4ddf98dad7cf21c72091c800f1bfac05} gratis. ¿Cómo? De la misma manera que su seguro de automóvil y los agentes de seguros del propietario trabajan – se les paga de las primas al transportista, que luego paga a los agentes. Trabajamos de la misma manera. No te cuesta nada.

Llámenos aquí o llame al 1-800-729-9590 las 24 horas del día.
¡Gracias por leer!

Chris Westfall

GE Retiree Options Outside the “Exchange” Save Money

GE employees should get a second opinion because they can save up to $1,000 per person, per year, starting in year ONE.

See the video:

Can you buy a Medicare plan outside the exchange? Yes.

As long as you buy at least the drug plan OR the Medicare plan through the exchange, you WILL get the reimbursement money.

When this same thing happened to AT&T retirees in 2014, we successfully helped them save, collectively, millions of dollars that would have otherwise gone to the most expensive insurers in their markets. They used those savings for other policies and as a cushion against future rate increases.

All they had to do was purchase the Part D drug plan through the exchange, and then entire reimbursement money was there to pay both premiums.

We provide a second opinion, and independent review of ALL of the plans available to you.
If you prefer to work with the exchange, a huge call center where you are likely to get a different new-hire every time you call in, you certainly can. If you want the benefit of 20 years of experience and true independence, call us for that second opinion.

You can call us 24 hours a day at 1-800-729-9590

If we’re not in the office, please leave your information on our phone so that we can call you first the next morning.



Weiss Medigap Report – only $49 for free rates

Over the 4th of July weekend, I received an e-mail offering a comparison of all of the Medicare Supplement rates in my area for ONLY $49!

This was such a deal because their usual cost is $99 for an unbiased quote of all Medicare Supplement plans in my area.

What a deal, right? Wrong.

I’m often asked by potential clients what my service costs.. for me to look up the rates and also provide them the background on the companies listed in the results.

Very happily, I tell them that our service costs them nothing, as it is included in the cost of the premiums, whether they went direct to the carrier OR used the service of an experienced agent.

No extra cost!

I did a video about my reaction, and show the e-mail from the company offering the $49 Medicare Supplement quote.

For the record, we do free quotes all the time and help with plan selection.
You can call us at 1-800-729-9590, even the call is free!


Medigap Hospital Discount Card Confusion

Yes, this is a pet peeve of mine – any time you can avoid confusion with senior clients, you should. Anything that introduces uncertainty and confusion in the mind of a brand new client is bad for business. It is therefore my goal to let you know what some insurance companies are sending to your clients with their policies and how you should get in front of it and answer the calls about it. –

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