How to find out what your Medicare plan will pay for

You can check your Medicare coverage in three ways: online through your plan's website, by calling the customer service number on your insurance card, or by reviewing the documents your plan mailed to you. The fastest route for a single question is usually a phone call, because a representative can tell you right away whether a specific doctor, drug, or service is covered. If you need to see a full list of what is and is not covered, the online tools and printed materials give you that detail all at once.

Your coverage depends on which type of Medicare plan you have — Original Medicare (Parts A and B), a Medicare Advantage plan (Part C), or a Medigap supplemental policy. Each type covers different things and has different rules about which doctors you can see and how much you pay. Knowing which plan you have is the first step.

Key Takeaways

  • Call the customer service number on your insurance card to ask about a specific doctor, drug, hospital, or procedure — this is the fastest way to get a yes or no answer.
  • Log into your plan's website to search for in-network doctors and pharmacies, or to view your full coverage documents.
  • Your plan mails you a Summary of Benefits and Coverage document each year that lists what is covered, what you pay, and what is not covered.
  • If you have Original Medicare, use Medicare.gov's search tools to find participating doctors and suppliers, or call 1-800-MEDICARE to ask about coverage for a specific service.
  • Coverage changes every January 1st, so check again if your plan sent you a new card or notice in the fall.

Calling your plan to check coverage for a specific service

Have your insurance card in front of you when you call. The customer service number is printed on the back. Tell the representative what you want to know — for example, "Does my plan cover a colonoscopy?" or "Is Dr. Sarah Johnson in my network?" — and they will tell you whether it is covered and what you will owe.

Ask the representative to spell out the exact cost: some services are covered at 100 percent, others require you to pay a copay (a fixed amount like $25), and still others require you to pay coinsurance (a percentage of the cost). If the representative is unsure, ask them to check with their supervisor or to send you the answer in writing. Write down the date, time, and representative's name in case you need to reference the conversation later.

Call during business hours listed on your card. Most plans have phone lines open Monday through Friday, 8 a.m. to 8 p.m., and some are open on weekends. If you are deaf or hard of hearing, ask for TTY services when you call.

Using your plan's website to search for doctors and drugs

Log into your plan's member portal using the username and password you set up when you first joined. If you do not have a login, go to your plan's main website and look for a "Member Login" or "Sign In" button. You may need your member ID number, which is on your insurance card.

Once you are logged in, look for a tool called "Find a Doctor," "Provider Search," or "Network Providers." Type in the doctor's name or specialty (like "cardiologist") and your zip code. The search will show you which doctors are in your network — meaning your plan has a contract with them and you will pay less to see them. If a doctor does not appear in the search, they are likely out of network, and you will pay more.

To check whether a drug is covered, use the "Prescription Drug Search" or "Formulary" tool. Type in the name of the medication and the dose. The tool will tell you whether it is on your plan's formulary (the list of drugs your plan covers), what tier it is on (which affects your cost), and whether you need prior authorization (permission from your plan before you fill it).

Reading your Summary of Benefits and Coverage document

Your plan mails you a document called the Summary of Benefits and Coverage (or SBC) every year, usually in September or October. This document lists what your plan covers, what you pay for each type of service, and what is not covered. It is written in a standard format so you can compare it to other plans if you are thinking about switching.

The SBC is organized by type of service: office visits, hospital stays, emergency care, prescription drugs, and so on. For each service, it shows what you pay (copay, coinsurance, or deductible) and whether there are limits on how many times you can use it. If something is listed as "Not covered," your plan will not pay for it, and you will owe the full cost.

Keep your SBC in a safe place. You will need it to compare plans during open enrollment in the fall, and it is useful to reference if you have a question about coverage. If you lost your copy, you can request a new one by calling your plan's customer service number or logging into your member portal.

Checking coverage if you have Original Medicare

If you have Original Medicare (Parts A and B) instead of a Medicare Advantage plan, you do not have a customer service number on an insurance card. Instead, go to Medicare.gov and use the "Care Provider Search" tool to find doctors, hospitals, and suppliers who accept Medicare. You can also call 1-800-MEDICARE (1-800-633-4227) to ask whether a specific service is covered.

Original Medicare covers most medically necessary services, but there are limits. For example, it covers hospital stays, doctor visits, and some preventive care at no cost, but it does not cover routine dental work, hearing aids, or most vision care. If you are unsure whether something is covered, the 1-800-MEDICARE line can tell you.

If you have a Medigap supplemental policy along with Original Medicare, you also have a separate insurance card for that policy. Call that number to ask what your Medigap plan covers in addition to Original Medicare.

What to do if a service is not covered

If your plan does not cover something you need, you have a few options. First, ask your doctor whether there is a similar service that is covered — for example, if your plan does not cover a brand-name drug, it may cover a generic version that works the same way. Second, ask your plan whether you can request an exception. Some plans will cover a service that is normally not covered if your doctor writes a letter explaining why you need it.

Third, you can file an appeal. If your plan denies coverage for something your doctor says you need, you have the right to ask the plan to reconsider. Your plan will send you instructions on how to appeal. Fourth, if you have Original Medicare and a service is not covered, you can look into whether a Medigap policy would cover it — different Medigap plans cover different things.

When your coverage changes

Medicare plans change their coverage every January 1st. In the fall (usually October and November), your plan will mail you a notice of changes and a new Summary of Benefits and Coverage. Read these documents carefully, because your costs, your network of doctors, or your covered drugs may be different in the new year.

If your plan is changing in a way that affects you — for example, your doctor is leaving the network or a drug you take is no longer covered — you have the right to switch plans. You can change plans during the Annual Enrollment Period, which runs from October 15 to December 7 each year. If you miss that window, you can only switch plans if you have a may have access to life event, such as moving to a new state or losing other insurance.

Frequently Asked Questions

How do I know if my doctor is in my plan's network?

Log into your plan's website and use the "Find a Doctor" search tool, or call your plan's customer service number and give them the doctor's name. If the doctor appears in the search results, they are in network. If not, they are out of network, and you will pay more to see them.

What does "prior authorization" mean?

Prior authorization means your plan wants to review your prescription before you fill it to make sure it is medically necessary. Your doctor's office usually handles this — they contact your plan, your plan approves or denies it, and then you fill the prescription. If your plan denies it, your doctor can appeal or suggest a different drug.

Can I see a doctor who is not in my network?

Yes, but you will pay more. With Original Medicare, you can see any doctor who accepts Medicare. With a Medicare Advantage plan, you can see an out-of-network doctor, but your copay or coinsurance will be higher. Some Medicare Advantage plans do not cover out-of-network care at all except in emergencies.

What happens if my plan stops covering a drug I take?

Your plan will mail you a notice before the change takes effect. Talk to your doctor about switching to a covered drug, or ask your plan whether you can request an exception. You can also switch to a different Medicare plan during the Annual Enrollment Period if the new plan covers your drug.

Is there a cost to check my coverage?

No. Calling your plan, using their website, and reviewing your coverage documents are all free. You are already paying for your plan, so these services are included.