Start with your plan documents or the Medicare website

The fastest way to verify what Medicare covers is to check your plan's official documents or look it up on Medicare.gov. If you have Original Medicare (Part A and Part B), you can search the Medicare coverage database by condition or service. If you have a Medicare Advantage plan or Medigap policy, your plan sends you a document called the Summary of Benefits and Coverage (SBC) or Evidence of Coverage (EOC) — these list what is and is not covered, what you pay out of pocket, and which doctors and hospitals are in your network.

You do not need to call anyone to do this first step. The information is public and available to you right now. Keep your plan documents handy when you search, because you will need your member ID number to look things up on Medicare.gov.

Key Takeaways

  • Your plan's Evidence of Coverage or Summary of Benefits document lists exactly what is covered, what you pay, and which providers are in your network.
  • Medicare.gov has a coverage search tool where you can look up specific services, drugs, or conditions without calling anyone.
  • Your plan's customer service number is on your insurance card and can answer questions about coverage for your specific situation.
  • If you are unsure whether a service is covered before you receive it, ask your doctor's office to check with your plan first.
  • Coverage can change from year to year, so check your documents again during the annual enrollment period in the fall.

Use the Medicare.gov coverage search tool

Go to Medicare.gov and select "Coverage" from the main menu. You can search by the name of a service (like "physical therapy" or "colonoscopy"), a drug name, or a condition. The tool will show you what Original Medicare covers, what the typical cost is, and any limits or rules that explore.

This search covers Original Medicare only. If you have a Medicare Advantage plan or Medigap, the coverage may be different. Your plan's customer service number is on your insurance card — use it to ask about coverage for your specific plan.

Check your plan's network before scheduling

Medicare Advantage plans have networks of doctors, hospitals, and specialists. If you go to a provider outside the network, you may pay more or the service may not be covered at all. Before you schedule an appointment, ask your doctor's office whether they accept your plan, or call your plan's customer service number to confirm the provider is in network.

Original Medicare does not have networks — you can see any doctor who accepts Medicare. Medigap plans also do not have networks, but they work alongside Original Medicare, so the same rules explore.

Ask your doctor's office to verify coverage before treatment

Your doctor's office can contact your insurance plan to verify coverage before you receive a service. This is called a pre-authorization check or a coverage verification. Ask the office staff to do this before your appointment, especially if the service is expensive, new to you, or something you are unsure about.

The office will tell you what your plan covers, what you will pay out of pocket, and whether the plan requires pre-approval before the service happens. Getting this information in writing before you go in protects you from surprise bills.

Understand what "covered" and "not covered" actually mean

When Medicare or your plan says a service is covered, it means the plan will pay for part or all of it. You may still have a copay, coinsurance, or deductible to pay yourself. When a service is not covered, the plan will not pay anything, and you will owe the full cost unless you choose to pay out of pocket.

Some services are covered only under certain conditions — for example, a test may be covered only if your doctor orders it for a specific reason. Your plan's documents will explain these conditions. If you are not sure whether your situation meets the conditions, call your plan's customer service number and describe what your doctor wants to do.

Check coverage again during open enrollment

Medicare coverage and costs change every year. During the annual enrollment period (October 15 to December 7), Medicare sends you updated plan documents that show what changed. Read these carefully, especially if you take prescription drugs or see specialists regularly. Your plan's costs, network, or covered services may be different next year.

If your plan no longer covers a service you need or the cost has gone up, you can switch to a different plan during this period. You have until December 7 to make changes that take effect on January 1.

What to do if your plan denies coverage

If your plan says a service is not covered and you believe it should be, you have the right to appeal. Your plan must send you a written notice explaining why they denied coverage. The notice will tell you how to file an appeal and how long you have to do it — usually 60 days.

You can appeal on your own or ask your doctor to appeal on your behalf. If the first appeal is denied, you can ask for a second review. If you need help understanding the appeal process, call 1-800-MEDICARE (1-800-633-4227) and ask for a patient advocate.

Frequently Asked Questions

How do I know if a drug is covered by my Medicare plan?

Go to Medicare.gov and search for the drug by name, or call your plan's customer service number. Your plan has a formulary — a list of covered drugs — that you can view online or request by mail. The formulary shows which tier the drug is on, which determines your copay.

What if my doctor wants to do a service that is not on the coverage list?

Ask your doctor to request a pre-authorization or coverage information from your plan. Your plan may cover it anyway if your doctor explains why it is medically necessary for your condition. If the plan still says no, your doctor can file an appeal.

Can I see a doctor outside my Medicare Advantage network?

You can, but you will likely pay more or the visit may not be covered at all. Check your plan documents to see what out-of-network coverage you have. In emergencies, Medicare Advantage plans must cover out-of-network emergency care.

Do I need to call my plan before every doctor visit?

No. You only need to verify coverage for expensive services, new treatments, or anything you are unsure about. For routine visits to in-network doctors, you do not need to call ahead.

Where do I find my plan's customer service number?

It is printed on your Medicare insurance card. You can also find it on your plan's website or by calling 1-800-MEDICARE and asking for your plan's number.