Doctor Networks & Drug Coverage
As an agent, you must ensure that your client’s doctors are in-network with their chosen plan and that their medications are covered. This prevents unexpected costs and ensures they receive the care they need. You can verify this information using Sunfire (Medicarelink) and Carrier Portals (UnitedHealthcare, Humana, Aetna, Wellcare, etc.).
Best Practice: Always verify both provider and drug coverage before enrolling a client to ensure they receive the best possible benefits without unexpected costs.
Verifying Doctors Are In-Network
Using Sunfire (Medicarelink):
- Enter the doctor’s name, specialty, and location.
- Sunfire will show which plans include the provider in their network.
- Compare different plans to find the best match for your client.
Using Carrier Portals:
- Log in to the carrier’s provider search tool.
- Search for the doctor under the specific plan the client is considering.
- Confirm network participation, office locations, and referral requirements (for HMOs).
Verifying Prescription Drug Coverage
Using Sunfire (Medicarelink):
- Enter each medication, including dosage and frequency.
- Sunfire will display formulary coverage, tier levels, and estimated drug costs for each plan.
- Compare plans to identify the most cost-effective option.
Using Carrier Portals:
- Search for the medications in the carrier’s drug formulary.
- Confirm if the drugs are covered, their tier level, and any restrictions (e.g., prior authorization or step therapy).
- Check for lower-cost alternatives, such as preferred pharmacies or mail-order options.
💊 What Are Drug Tiers?
Medicare Part D (and Medicare Advantage plans with drug coverage) organizes covered prescription drugs into tiers. Each tier has different cost-sharing amounts, and generally:
Lower tiers = lower cost drugs
Higher tiers = higher cost drugs
📊 Drug Tier Chart with Icons
| Tier | Name | Drug Type | Typical Cost 💲 | Example |
|---|---|---|---|---|
| 🟢 1 | Preferred Generics | Common, low-cost generic drugs | 💲 Low | Lisinopril, Metformin |
| 🔵 2 | Generics | Other generic drugs | 💲💲 Moderate | Simvastatin, Omeprazole |
| 🟠 3 | Preferred Brands | Brand-name drugs with plan deals | 💲💲💲 Higher | Januvia, Advair |
| 🔴 4 | Non-Preferred Drugs | Non-preferred brand & some higher generics | 💲💲💲💲 Expensive | Xarelto, Celebrex |
| ⚫ 5 | Specialty Tier | High-cost, complex medications | 💲💲💲💲💲 Very High | Humira, Enbrel, some cancer meds |
🧠 Tips for Clients:
✅ Always check the plan’s formulary to see which tier your drug is in.
💊 Generics can save money—ask your doctor if one is available.
🧾 Each plan is different—a drug could be Tier 3 in one plan and Tier 2 in another.
📞 If a drug is too expensive, you may request a tier exception from the plan.