Frequently Asked Questions
About Medicare & Insurance

The Medicare Initial Enrollment Period (IEP) is a 7-month window during which you can first enroll in Medicare when you turn 65. It begins 3 months before your 65th birthday month, includes your birthday month, and ends 3 months after. This is the primary enrollment opportunity for most people turning 65.

Missing your IEP without a qualifying Special Enrollment Period can result in permanent late enrollment penalties added to your monthly premiums for as long as you have Medicare. Learn about all enrollment windows →

If you are actively employed and covered by an employer's group health plan through your own current employment, you can generally delay Medicare enrollment without penalty. In this case, you would qualify for a Special Enrollment Period when you eventually lose that employer coverage.

However, COBRA, retiree coverage, marketplace plans, and VA benefits do not qualify as exceptions to Medicare's enrollment requirements. If you are in any of these situations and delay Medicare, you may face permanent penalties. Always verify your specific situation with a licensed advisor before deciding to delay.

A Medicare Special Enrollment Period (SEP) allows you to enroll in or change Medicare outside of standard enrollment windows when a qualifying life event occurs. Common qualifying events include losing employer health coverage, moving to a new service area, or your plan leaving the Medicare program.

Most SEPs last 2 months from the qualifying event. Missing your SEP window means waiting for the next General Enrollment Period (January 1 – March 31), with coverage starting the first day of the month after you sign up — and potentially facing late enrollment penalties. See all enrollment windows →

You can change your Medicare Advantage or Part D drug plan each year during the Annual Enrollment Period (AEP), which runs October 15 through December 7, with changes effective January 1.

There is also a Medicare Advantage Open Enrollment Period from January 1 to March 31, during which you can switch from one Advantage plan to another or return to Original Medicare. Outside of these windows, changes are generally only allowed with a qualifying Special Enrollment Period. A PharmSurance advisor can review your plan every year before AEP to ensure you're still on the best option. Read our enrollment windows guide →

Medicare is divided into four parts: Part A covers hospital care, Part B covers outpatient and doctor visits, Part C (Medicare Advantage) is a private plan that bundles A and B, and Part D covers prescription drugs.

Part A is premium-free for most people. Part B has a monthly premium. Part C replaces Original Medicare through a private insurer and usually includes Part D. Part D is a separate drug plan added to Original Medicare. Choosing the right combination depends on your health, your medications, and your budget.

Original Medicare (Parts A and B) is government-run and lets you see any doctor who accepts Medicare nationwide. Medicare Advantage (Part C) is offered by private insurers approved by Medicare — it generally uses a provider network.

With Original Medicare, your share of covered costs has no built-in maximum unless you add a Supplement plan. Medicare Advantage plans are required to have an out-of-pocket maximum. The best choice depends on your health, your providers, and how much predictability you want in your costs.

A Medicare Supplement plan, also called Medigap, is private insurance that works alongside Original Medicare to cover costs Medicare doesn't pay — such as copays, coinsurance, and deductibles.

Medigap plans are standardized by letter (Plan G, Plan N, etc.) and sold by private insurers. They do not include prescription drug coverage, so you would also need a separate Part D plan. The significant advantage of Medigap is that most plans let you see any Medicare-accepting doctor in the country without network restrictions. Enrollment during your 6-month Medigap Open Enrollment Period is critical — after that window, insurers can deny coverage or charge more based on health conditions. Read our full Medigap guide →

With Original Medicare or a Medigap plan, you can see any doctor in the US who accepts Medicare — which includes the vast majority of physicians. With Medicare Advantage, you are limited to the plan's provider network.

Before recommending any Medicare Advantage plan, a PharmSurance advisor verifies that your current primary care physician, specialists, and preferred hospitals are in-network. This is a step that is easy to overlook but can have major consequences if your doctors are excluded from coverage. Compare Medicare Advantage vs. Original Medicare →

Medicare Part A is premium-free for most people who worked and paid Medicare taxes for at least 10 years. Part B carries a standard monthly premium, set annually by the federal government, and higher earners pay more based on income.

Costs vary across the different ways people get their Medicare coverage — a PharmSurance advisor can walk you through what applies to your situation.

The Medicare late enrollment penalty is a permanent premium increase applied when you miss your enrollment window without a qualifying exception. For Part B, the penalty applies for every 12-month period you were eligible but did not enroll — and it never goes away.

For Part D (drug coverage), a separate permanent penalty applies based on how many months you went without qualifying drug coverage. Both penalties are added to your monthly premiums for the entire time you have Medicare. This is why enrolling on time — or working with an advisor to understand your specific situation — is so important. See our Medicare costs guide →

The Medicare "donut hole" (coverage gap) was permanently eliminated as of 2025 Read our Part D cap guide →, replaced by a hard annual cap on out-of-pocket prescription drug costs. The old system, which required higher cost-sharing once spending hit a certain threshold, no longer exists.

As of 2026, out-of-pocket drug costs under Part D are capped annually — the cap amount is set by the federal government and adjusts each year for drug cost inflation. Once you reach that cap, your plan covers 100% of your covered medication costs for the rest of the year. A PharmSurance advisor can help you understand how your specific medications interact with your plan's cost structure throughout the year. Read our drug coverage guide →

The Medicare Prescription Payment Plan (sometimes called M3P) lets you spread your out-of-pocket Part D drug costs into monthly payments across the calendar year instead of paying the full amount at the pharmacy counter. It's a voluntary program available to anyone with Medicare drug coverage, including standalone Part D plans and Medicare Advantage plans with drug coverage.

If you opt in, you pay nothing at the pharmacy for covered prescriptions — instead, your plan bills you monthly based on what you owe and how many months remain in the year. Important: this program does not lower your total drug costs. It simply spreads the same costs out over time, which can make a big difference if you'd otherwise face a large bill early in the year. It tends to make the most sense for people with high prescription costs, especially those approaching their plan's annual out-of-pocket cap. You can enroll or leave the program at any time by contacting your plan, though enrolling late in the year (after September) usually offers little benefit since fewer months remain to spread costs over. Learn about the Part D out-of-pocket cap →

Medicare prescription drug coverage (Part D) is provided through private plans approved by Medicare — either as a standalone drug plan added to Original Medicare, or built into a Medicare Advantage plan.

Each plan maintains its own list of covered drugs, organized into tiers that affect what you pay. Plans vary in which drugs they cover. Reviewing your specific medications against a plan before enrolling is worth doing. Our pharmacy professional advisors review your medication list before making any recommendation. See how drug coverage works →

Your Medicare drug plan can meaningfully affect your out-of-pocket healthcare costs — especially if you take multiple medications or any high-cost specialty drugs.

How a medication is treated can vary depending on which plan you're on. PharmSurance advisors bring clinical pharmacy knowledge to this process — they understand coverage tiers, prior authorization requirements, step therapy, and how to help you understand your options for your specific medications. They also track brand-name drugs approaching generic availability, which can be worth knowing about ahead of time.

If your medication is not on your plan's formulary, you may pay full price, request an exception, or appeal the decision through your plan.

You can file an exception request asking the plan to cover the drug at a lower cost tier if there is a medical reason. Your prescriber must support this request. If denied, you have the right to appeal. You can also ask your doctor about therapeutic alternatives — similar medications that may be covered differently. A PharmSurance advisor can help you understand your options and avoid this situation in the first place by reviewing coverage before you enroll. Read our drug coverage guide →

Working with a licensed Medicare advisor is always at no cost to you. Advisors are compensated by the insurance carriers when you enroll in a plan — not by you, and not through any fee.

This compensation is set by the carrier and is the same regardless of which plan the advisor recommends, which means there is no financial incentive to steer you toward any specific plan. PharmSurance advisors are legally and ethically required to recommend the plan that best fits your individual needs.

Your premium is also identical whether you enroll directly with the insurance company or through PharmSurance — carrier premiums are filed and priced the same way regardless of how you sign up, so going direct doesn't save you anything. What going direct does cost you is the comparison itself: a call to the carrier only tells you about that carrier's own plans, while a PharmSurance advisor reviews options across multiple carriers and gives you a personalized, unbiased recommendation based on your specific health needs and medications — not just whatever one company happens to be selling.

PharmSurance advisors are pharmacists and pharmacy technicians — licensed insurance advisors who bring clinical healthcare expertise to every Medicare conversation.

Most insurance advisors understand plan structures and premiums. PharmSurance advisors also understand prescription coverage, medication interactions, prior authorization processes, and how your specific health picture connects to your coverage needs. This pharmacy-first perspective means your Medicare plan is evaluated not just by cost — but by how well it actually works for your health.

A licensed Medicare advisor is legally required to present options that fit your needs — not to push a specific product. PharmSurance advisors follow this standard strictly, and add a clinical perspective that further aligns with your health interests rather than any sales goal.

If the right answer for your situation is staying on your current plan, we will tell you that. If we can't serve you because your state isn't currently in our coverage area, we will tell you that too — and it's usually just a matter of asking, since we'll work hard to get an advisor licensed in your area once you let us know you're interested, keeping you updated the whole time. Our long-term goal is a client who trusts us — and that requires honesty from the very first conversation.

Yes — pharmacists and pharmacy technicians can become licensed Medicare insurance agents by obtaining a state insurance producer license, which requires completing a pre-licensing course and passing a state exam.

PharmSurance was built specifically to support pharmacy professionals through this process — providing training, licensing guidance, compliance resources, and ongoing support at no cost. The pharmacy background is a significant professional advantage in the Medicare advisory role.

Medicare insurance agents earn commissions from carriers when clients enroll in plans — and those commissions typically renew automatically each year the client stays on their plan, creating a compounding income stream over time.

Commission amounts vary by plan type and carrier. The compounding nature of renewals means that advisors who build consistently over time can generate meaningful recurring income that grows independently of ongoing work volume. PharmSurance provides full transparency on commission structures when you join the network.

No — joining the PharmSurance network comes at no cost. PharmSurance never charges its advisors a membership fee, platform fee, or any other ongoing cost.

The only cost associated with getting started is your state insurance producer licensing — which typically involves a pre-licensing course and exam fee, usually less than a few hundred dollars total. PharmSurance provides training and guidance for this process at no charge. We are compensated by carriers through a standard FMO arrangement, which does not reduce your commission in any way.

No — not at all. The vast majority of our advisors keep their pharmacy roles and add Medicare advising alongside them. This is designed to be additive, not an either/or career change.

Because you set your own schedule and there are no quotas, you decide exactly how much you take on. Some advisors help a handful of patients each enrollment season as a supplemental income stream; others build it into a larger part of their practice over time. Whether you're a full-time pharmacist, work part-time, have stepped away from pharmacy, or are retired, you can participate on whatever terms fit your life.

Most pharmacy professionals are fully licensed and ready to advise within 6–7 weeks, at a total out-of-pocket cost usually under a few hundred dollars.

The process involves a state-approved pre-licensing course (typically 20–40 hours, which you can complete at your own pace), a licensing exam fee, and a state application fee. Exact costs vary by state. PharmSurance provides the training, study guidance, and step-by-step support to get you through it — at no charge. There are no hidden fees and nothing to pay PharmSurance, ever.

AEP stands for the Annual Enrollment Period — October 15 to December 7 each year — when most Medicare beneficiaries can change their plans. It's the busiest and most important window for Medicare advisors.

The majority of Medicare enrollments happen during these roughly six weeks, which is why many advisors concentrate much of their yearly activity (and income) in the fall. There are other enrollment windows throughout the year — like the Medicare Advantage Open Enrollment Period and various Special Enrollment Periods — but AEP is the centerpiece of the Medicare calendar. PharmSurance helps you prepare so you can make the most of it.

Yes — like all Medicare advisors, you'll need Errors & Omissions (E&O) insurance and appointments with the carriers whose plans you want to offer. PharmSurance walks you through both as part of getting started.

E&O insurance is standard professional liability coverage for insurance producers and is typically very affordable. Carrier appointments are the approvals that allow you to offer a specific company's plans — each requires completing that carrier's annual certification. We guide you through which carriers to appoint with, how to complete certifications, and how to set everything up correctly, so nothing falls through the cracks.