Health plan must‑haves

Tips to get the quality care you need at a cost you can afford

When choosing an ACA health plan, the most important must-haves are affordable total costs, coverage for your medications and doctors, predictable out‑of‑pocket expenses, and access to preventive, mental health and virtual care.

These eight factors can help you choose a health plan that balances the care you need with the costs you can afford. They apply to ACA‑compliant individual and family health plans, including plans offered through the Health Insurance Marketplace^®.

1. A deductible and out‑of‑pocket maximum you can live with

If you only compare monthly premiums, you might miss the bigger question: How much could you pay in a year if you need care? 

Know these two numbers:

• Deductible: the amount you pay before your plan begins covering many services (not always all services). 
• Out‑of‑pocket maximum: the most you’ll pay in a year for covered services (after that, the plan pays more). 

What to look for

• A deductible that fits your savings and risk comfort 
• An out‑of‑pocket max that won’t derail your budget if something unexpected happens 
• Cost details that are easy to find (so you’re not surprised later) 

Good to know: Many plans cover certain care before you meet your deductible – like preventive care or specific visits – so check the plan details.

2. Copays and coinsurance that match how you use care

Two plans can have the same premium and deductible, but feel very different once you start using them.

Common cost types

• Copay: a fixed amount (example: $30 for a primary care visit)
• Coinsurance: a percentage (example: you pay 20% of the cost)

What to look for

• Predictable copays for the care you use most (primary care, urgent care, specialists, mental health)
• Clear coinsurance amounts for services like imaging, labs or outpatient procedures
• A simple way to estimate costs for common services

3. Prescription coverage that keeps medication affordable

Prescription costs can add up quickly, even if you only take a few medications.

What to check

• Is your medication covered? (Formulary coverage varies by plan)
• What tier is it on? (Generic, preferred brand, specialty, etc.)
• What will you pay? (Copay/coinsurance can differ by tier)
• Are there requirements? Some prescriptions require prior authorization or step therapy.

What to look for

• Low copays for generics
• Transparent pricing for brand and specialty medications
• A convenient pharmacy network

4. Support for chronic conditions (and predictable costs)

If you manage a chronic condition – like diabetes, asthma, high blood pressure, or heart disease – the right plan can make care easier and more affordable.

What to look for

• Coverage for routine visits and monitoring
• Access to programs that support ongoing care
• Reliable costs for common chronic‑care needs

Explore: MyPriority chronic condition coverage.

5. Virtual care that’s convenient and clearly priced

Virtual care can save time (and sometimes money), especially for common illnesses and quick questions.

What to check

• Is virtual urgent care included?
• Is it available 24/7 or only during certain hours?
• What does it cost—$0, copay or deductible/coinsurance?
• Does virtual care connect you to prescriptions when appropriate?

What to look for

• Easy access when you need it
• Clear pricing that doesn’t require digging
• Options for urgent care and behavioral health (if offered)

Explore: How does virtual care work?

6. A provider network that works for you

Seeing an out‑of‑network doctor or hospital can cost significantly more. That’s why your network is one of the most important “must‑haves.”

What to check

• Are your preferred doctors, specialists, and hospitals in‑network?
• Do you need a referral to see a specialist?
• Is the network strong where you live, work or travel?

What to look for

• A broad network that includes the care you want close to home
• Straightforward specialist access (depending on plan type)
• Tools that make it easy to confirm network status

Explore: Understanding health plan networks

7. Preventive care and mental health benefits you’ll actually use

Staying healthy is easier when preventive care is accessible and when mental health support is part of the plan, not an afterthought.

What to check

• Preventive services and screenings (and whether they’re covered before the deductible)
• Mental health and substance use support (therapy, psychiatry, programs)
• Availability of in‑network providers for behavioral health

What to look for

• Clear coverage details and easy access to appointments
• Support options beyond in‑person visits (virtual therapy, coaching, etc.)

Explore: Understand preventive care

8. Valuable extras that help you save (and stay well)

Many plans include extra perks and programs at no added charge. These can improve your health and stretch your benefits further.

Examples of plan extras

• Fitness and wellness discounts
• Hearing discounts
• Travel support or global assistance
• Digital tools and resources to help you reach health goals

What to look for

• Extras you’ll realistically use
• Programs that reduce barriers to care or support healthier habits

Explore: Why choose Priority Health

Putting it together: choose a plan that fits your life

When you compare plans, don’t just ask “What’s the premium?”

Ask:

1. What will I pay when I get care?
2. Are my doctors and hospitals in‑network?
3. Are my prescriptions covered and affordable?
4. What’s my worst‑case cost for the year?
5. What support is available if I manage a condition or need mental health care?

FAQs