Before choosing a Medicare plan, check whether your preferred doctors, specialists, hospitals and pharmacies are in-network and confirm that each prescription you take is listed on the plan’s covered drug list, also called a formulary. Reviewing these details before you enroll can help you avoid unexpected costs, coverage issues or disruptions in care.
Before you enroll: Ask these 5 coverage questions
- Is my primary care doctor in-network?
- Are my specialists covered?
- Is my preferred hospital in-network?
- Are my prescription medications on the plan's formulary?
- Can I use my preferred pharmacy?
Checking these items before enrolling may help you avoid unexpected costs and interruptions in care.
Why it matters to check coverage before enrolling
When you compare Medicare plans, it is easy to focus on the monthly premium. But the plan that looks affordable at first may not be the best fit if your doctors are out-of-network, your hospital is not included or your medications are not covered. Provider access and prescription drug coverage can affect both your costs and your ability to continue receiving care from the people and places you trust.
Taking time to review a plan’s provider directory, pharmacy directory and formulary can give you a clearer picture of what you may pay throughout the year. It can also help you identify questions to ask before you enroll.
How to check if your doctors are in-network
Many Medicare Advantage plans use provider networks. A network is a group of doctors, hospitals and other health care professionals that contract with a health plan to provide covered services. If you use an in-network provider, your costs are often lower than they would be with an out-of-network provider.
Before enrolling, search the plan’s provider directory for your primary care provider, specialists, hospitals, urgent care centers and other facilities you use. Be sure to search by the specific plan you are considering, because a provider may participate in one plan network but not another.
- Check your primary care provider
- Confirm any specialists you see regularly
- Look up your preferred hospital or health system
- Review urgent care, lab, imaging and outpatient facility options
- Call the provider’s office or the health plan if you are unsure
How to check prescription drug coverage
Prescription drug coverage can vary from plan to plan. A plan’s formulary, or drug list, shows which medications are covered and may include rules for how those medications can be filled.
When comparing plans, make a list of each prescription you take, including the exact name, dosage and how often you take it. Then search the plan’s drug list to see whether each medication is covered and what your estimated cost may be.
- Confirm whether each medication is covered
- Check the drug tier for each medication
- Review copays, coinsurance and deductible details
- Look for restrictions, such as prior authorization, quantity limits or step therapy
- Compare costs at in-network and preferred pharmacies, if available
What drug tiers mean
Many Medicare prescription drug plans group covered medications into tiers. In general, drugs on lower tiers cost less, while drugs on higher tiers may cost more. Tier placement can vary by plan, so the same drug may have a different cost depending on which plan you choose.
| Drug tier | What it often means |
|---|---|
| Lower tier | May include generic or preferred medications with lower out-of-pocket costs |
| Middle tier | May include preferred brand-name medications or higher-cost generics |
| Higher tier | May include non-preferred brand-name drugs or specialty medications with higher costs |
How to check pharmacies
Your pharmacy can also affect what you pay. Some Medicare plans have pharmacy networks, and some may offer lower costs at preferred pharmacies. Before enrolling, check whether your current pharmacy is in-network and compare estimated drug costs at other nearby or mail-order pharmacies.
What to do if your doctor or medication is not covered
If a doctor, hospital, pharmacy or prescription is not covered by a plan you are considering, do not assume you are out of options. You may be able to compare other plans, ask your provider whether they participate in another network, ask your doctor about a covered medication alternative or contact the plan for help understanding your options.
- Compare another Medicare plan available in your area
- Ask whether your provider participates in a different plan network
- Ask your doctor whether a covered alternative medication may work for you
- Review whether the plan allows exceptions or coverage determinations
- Contact the health plan before enrolling if anything is unclear
Coverage checklist before you choose a Medicare plan
- Search for your primary care provider
- Search for your specialists
- Confirm your preferred hospital and health system
- Check urgent care, lab and outpatient facility access
- Make a list of your prescriptions, dosages and refill needs
- Review the plan’s formulary and drug tiers
- Check pharmacy network and preferred pharmacy options
- Compare estimated costs, not just monthly premiums
- Call the plan or provider’s office if you need confirmation
Frequently asked questions
How do I know if my doctor accepts a Medicare plan?
How do I know if my doctor accepts a Medicare plan?
Use the plan’s provider directory to search for your doctor by name, location and specialty. Because networks can vary by plan, confirm that the doctor is in-network for the specific Medicare plan you are considering.
When shopping for a Priority Health Medicare Advantage plan, you can search for your doctors and hospitals as you compare plan options.
What is a Medicare formulary?
What is a Medicare formulary?
A formulary is a list of covered prescription drugs. It can show whether a medication is covered, which tier it is on and whether any coverage rules apply.
When shopping for a Priority Health Medicare Advantage plan, you can search for your prescriptions as you compare plan options.
Can my prescription cost change depending on the pharmacy?
Can my prescription cost change depending on the pharmacy?
Yes. Your cost may vary depending on whether the pharmacy is in-network, preferred or standard, and whether you use retail or mail-order pharmacy options.
What if my doctor is not in-network?
What if my doctor is not in-network?
If your doctor is not in-network, compare other plans, ask the provider’s office whether they participate in another network or contact the health plan to understand your options before enrolling.
What if my medication is not covered?
What if my medication is not covered?
If a medication is not covered, ask your doctor whether a covered alternative may be appropriate. You can also compare other plans or contact the plan to ask about coverage rules, exceptions or next steps.
Compare Medicare Advantage plans with confidence
Now that you know how to check your doctors, hospitals and prescriptions, learn what else to look for when comparing Medicare Advantage plans, including costs, benefits, network access and prescription coverage.
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