Medicare Advantage plans are marketed heavily — particularly during the Annual Enrollment Period. The TV ads and mailers often emphasize $0 premiums, dental benefits, and grocery allowances. But the plan that looks best in a TV spot may not be the plan that's best for your health and your wallet. Here are five questions that will tell you far more than any advertisement.
1. Are my doctors in-network?
This is the most important question, and the answer must be verified directly — not assumed. Provider networks change from year to year. A doctor who was in-network last year may not be this year. Before enrolling in any Medicare Advantage plan, call each of your doctors' offices and ask them to confirm they accept that specific plan for the upcoming year. Don't rely solely on the carrier's online directory, which can be outdated.
If you have a specialist you see regularly — cardiologist, oncologist, endocrinologist — this question is even more critical. Losing access to a specialist mid-treatment can be both medically and financially disruptive.
2. Are my prescriptions on the formulary, and at what tier?
Every Part D plan (and Medicare Advantage plan with drug coverage) has a formulary — a list of covered drugs. But being on the formulary isn't enough. You also need to know which tier your drug is on, because your copay or coinsurance depends on the tier.
A brand-name drug on a preferred tier might cost you $45/month. The same drug on a non-preferred tier might cost you $95/month or 33% coinsurance with no cap. Use Medicare's Plan Finder at medicare.gov to run a cost comparison based on your specific drug list.
3. What is the plan's out-of-pocket maximum (MOOP)?
Every Medicare Advantage plan must set an annual out-of-pocket maximum — the most you'll pay for covered Part A and Part B services in a year. In 2025, the maximum allowed MOOP is $9,350 for in-network care and $14,000 for combined in- and out-of-network care.
Don't just note that a MOOP exists — compare the actual numbers. A plan with a $3,500 MOOP and a modest premium may be far better protection than a $0-premium plan with a $9,000 MOOP if you have significant health needs.
4. Does the plan require prior authorization for services I need?
Medicare Advantage plans can require prior authorization before they'll cover certain services — imaging, specialist visits, outpatient procedures, and more. This is legal and common, but it adds administrative burden and can delay care. Ask your current doctors whether prior authorization has been an issue with the plan you're considering, and check the plan's coverage policies for the services you use most.
5. Will this plan still be available (and this good) next year?
Medicare Advantage plan details are set annually. The plan you enroll in today may have different premiums, benefits, networks, and formularies next October. There's no guarantee that what you're getting this year will still be available or affordable next year.
This isn't a reason to avoid Medicare Advantage — it's a reason to conduct an annual review every fall during the Annual Enrollment Period. A good agent will proactively contact you every year to review changes in your plan.
We Do This Work for You
Evaluating Medicare Advantage plans across multiple carriers, networks, and formularies is exactly what Insurance Innovators LLC does. We'll verify your doctors, run your drug list, and compare plans side by side — at no cost to you. Call us at (530) 395-5309.