What to compare when you're looking at Medicare Advantage plans

Medicare Advantage plans differ in three main ways: the doctors and hospitals you can use, what you pay out of pocket, and which drugs they cover. You cannot compare them fairly by looking at the monthly premium alone — a plan with a low or zero premium might have high copays at the doctor, or it might not include the specialist you see regularly. The comparison tools Medicare provides let you filter by these things one at a time, but you have to do the work of checking all three for each plan you're considering.

Start by listing the doctors, hospitals, and pharmacies you use now. Then check whether each plan you're interested in includes them in its network. If a doctor is not in the network, you will pay more to see them — sometimes much more. Next, look at the cost structure: the monthly premium, the deductible (the amount you pay before the plan starts sharing costs), copays for office visits and specialist appointments, and coinsurance (the percentage you pay for hospital stays or procedures). Finally, check the drug formulary — the list of medications the plan covers — for any prescriptions you take regularly.

Key Takeaways

  • Use Medicare.gov's plan comparison tool to see which doctors, hospitals, and pharmacies are in each plan's network before you choose.
  • Compare the full cost picture: monthly premium, deductible, copays for visits and specialists, and coinsurance for hospital or surgery, not just the premium.
  • Check the drug formulary for each plan to confirm it covers your current medications at a cost you can afford.
  • Call the plan directly to ask about coverage for any procedure or specialist visit you know you will need in the coming year.
  • Plans change their networks and drug coverage every year, so you must compare again during open enrollment even if you were happy with your plan last year.

Using Medicare.gov to compare plans in your area

Go to Medicare.gov and select "Find Care Providers" or use the "Plan Finder" tool. Enter your ZIP code and the date your coverage will start. The tool will show you all Medicare Advantage plans available in your area. You can filter by plan type (HMO, PPO, or PFFS — each has different rules about which doctors you can see), and you can search for a specific doctor or hospital to see which plans include them.

The Plan Finder shows you the monthly premium, annual deductible, and copay amounts for common visits like a doctor's office appointment or an urgent care visit. It also displays the plan's out-of-pocket maximum — the most you will pay in a year before the plan covers everything at no cost. Write down these numbers for each plan you are considering. Do not rely on memory; the differences matter, and they are straightforward to mix up when you are looking at several plans at once.

Checking whether your doctors and hospitals are in the network

Each Medicare Advantage plan contracts with a specific set of doctors and hospitals. If you see a doctor who is not in the plan's network, you will usually pay a higher copay or coinsurance, or you may have to pay the full bill yourself. Some plans, called PPOs, let you see out-of-network doctors but charge you more. HMOs typically require you to use in-network doctors except in emergencies.

Search for each doctor you see regularly by name on the plan's website or call the plan's customer service number and ask directly. Do the same for your hospital, any specialists you visit, and your pharmacy. If a doctor you need is not in the network, ask the plan whether they have a similar specialist nearby, or call the doctor's office to ask whether they accept that plan. Some doctors are in the process of joining or leaving a network, and the online list may not be current.

Understanding the cost breakdown for each plan

Medicare Advantage plans charge you in several ways. The monthly premium is what you pay to the plan each month — this is separate from your Part B premium, which you still pay to Medicare. The annual deductible is the amount you must pay out of pocket before the plan starts to help pay for care. The copay is a fixed dollar amount you pay for a specific service, like a $25 copay for a doctor's visit. The coinsurance is a percentage of the cost you pay — for example, you might pay 20 percent of the cost of a hospital stay.

Add up what you expect to pay in a year for each plan. If you know you will have surgery or a hospital stay, ask the plan what the coinsurance will be and calculate the total. If you take several medications, add up the copays for those drugs. A plan with a low premium but high copays and coinsurance might cost you more in the end than a plan with a higher premium but lower copays. The out-of-pocket maximum is the most important number to know — once you reach it, the plan pays for everything else for the rest of the year.

Checking drug coverage and costs

Each Medicare Advantage plan has a formulary — a list of medications it covers. Plans are not required to cover every drug, and they often charge different copays for different medications. Some plans charge more for brand-name drugs and less for generics. Others require you to try a generic first before they will cover the brand name.

Go to Medicare.gov and use the "Drug Coverage" tool, or visit the plan's website and search for your medications by name. Write down the copay for each drug you take. If a medication you need is not on the formulary, call the plan and ask whether they will cover it under an exception, or whether a similar drug is covered instead. If your doctor prescribes a new medication during the year, check the formulary before you fill it, because the copay might be higher than you expect.

Comparing plans side by side with a worksheet

Create a straightforward table with the plan names across the top and the information you need to compare down the left side. Include the monthly premium, annual deductible, copay for a primary care visit, copay for a specialist visit, coinsurance for hospital stays, out-of-pocket maximum, and whether your main doctors and pharmacy are in the network. Add rows for the copays of your regular medications. Fill in the numbers for each plan you are considering.

This worksheet makes it straightforward to see at a glance which plan has the lowest premium, which has the lowest out-of-pocket maximum, and which includes all your doctors. You may find that no single plan is best in every category — one plan might have lower copays but a higher deductible, while another has a higher premium but includes your preferred hospital. Your job is to decide which trade-offs matter most to you based on how often you expect to use care and which doctors you need to see.

Questions to ask the plan before you choose

After you have narrowed your choices to two or three plans, call each plan's customer service number and ask about anything you are unsure of. Ask whether the plan covers any procedures or treatments you know you will need in the coming year. Ask about prior authorization — some plans require you to get permission from the plan before you have certain procedures, and the process can take time. Ask what happens if you travel out of state and need care. Ask about mental health coverage and whether the plan covers the therapist or psychiatrist you see.

Write down the answers and the date and time you called, in case you need to refer back to what you were told. If a plan representative tells you something that contradicts what the plan's website says, ask them to send you the information in writing so you have a record of it.

When to compare plans and how often to do it

Medicare Advantage plans change their networks, drug coverage, and costs every year. A plan that was perfect for you last year might have dropped your doctor from the network or raised your copays. You can compare plans and change to a different one during the Annual Enrollment Period, which runs from October 15 to December 7 each year. Your new coverage starts on January 1.

If you miss the enrollment period, you cannot change plans until the next year unless you have a may have access to life event — such as moving to a new state, losing other health coverage, or getting married. Some people also have a Special Enrollment Period if they are newly may be able to access for Medicare. Check Medicare.gov in September to see which plans will be available in your area starting January 1, so you have time to compare before the enrollment period opens.

Frequently Asked Questions

What is the difference between an HMO and a PPO Medicare Advantage plan?

An HMO requires you to choose a primary care doctor and get referrals to see specialists; you can only see in-network doctors except in emergencies. A PPO lets you see any doctor without a referral, but you pay more if you go out of network. PPOs cost more in premiums but give you more flexibility. Choose based on whether you are willing to stick with one doctor's recommendations or whether you prefer to manage your own care.

Can I change Medicare Advantage plans if I realize I made a mistake?

You can change plans during the Annual Enrollment Period (October 15 to December 7) or if you have a may have access to life event like moving or losing other coverage. If you enrolled in a plan and realize your doctor is not in the network, call the plan when ready and ask about exceptions or appeal options. Some plans will cover out-of-network care in limited situations if you were already seeing the doctor before you joined.

What does "prior authorization" mean, and how does it affect me?

Prior authorization means the plan requires you to get permission before you have a procedure or start a medication. Your doctor's office usually handles this, but it can delay care by a few days. Ask each plan which procedures or medications require prior authorization, especially for any care you know you will need soon.

Do I still pay my Part B premium if I choose a Medicare Advantage plan?

Yes. You pay your Part B premium to Medicare and your Medicare Advantage plan premium to the plan. Some plans have a zero premium, meaning you only pay Part B. Others charge an additional monthly premium on top of Part B. The plan premium is separate from copays and deductibles you pay when you use care.

What if my medication is not on the plan's formulary?

Call the plan and ask whether they will cover it under an exception, or whether a similar medication is covered instead. Your doctor can also request an exception in writing if they believe the medication is medically necessary. The plan must respond to the exception request within 72 hours. If the plan denies the exception, you can appeal the decision.