How to Shop for Medicare Advantage Plans: Key Questions

How to shop for Medicare Advantage plans: a practical, question-driven guide

Shopping for Medicare Advantage plans can feel overwhelming, but a focused set of questions will direct your comparison and reduce surprises. Below I summarize the most important items I ask clients in my practice and explain how to evaluate answers so you can make an informed choice.

Why these questions matter

Medicare Advantage plans are offered by private insurers and can differ widely in monthly premiums, provider networks, drug formularies, out-of-pocket limits, and extra benefits. Choosing based only on premium often causes higher total costs or restricted access to preferred doctors. The questions below help you weigh tradeoffs between price, access, and coverage quality.

Checklist of key questions to ask (and why)

1. What is the total expected cost?

• Ask about the monthly premium, deductible (if any), copayments/coinsurance for primary care, specialists, urgent care and inpatient stays, and the plan’s annual out-of-pocket maximum. A low premium may hide high copays or a steep deductible.
• Look at typical scenario costs (e.g., two PCP visits, one specialist, three prescription fills) to compare plans realistically.

1. Is my doctor/hospital in-network?

• Confirm that your primary care doctor, specialists you use, and local hospitals are included. If you need frequent specialist care, a plan with strong network access matters most.
• Check whether the plan requires referrals or prior authorizations for specialist care.

1. Are my prescription drugs covered (and at what tier)?

• Review the plan formulary for every medication you take, including the exact dose and strength. Check tiers, prior authorization rules, step therapy, and mail-order options.
• If a drug is out of formulary, ask whether a medical exception, appeal, or a covered therapeutic alternative exists.

1. What extras does the plan include?

• Many plans add dental, vision, hearing, fitness memberships, transportation or over-the-counter allowances. Decide which extras matter and whether their value justifies plan selection.

1. What is the plan’s quality rating and complaints record?

• Medicare publishes Star Ratings and complaint/appeals information. Higher-rated plans often deliver better customer service and fewer access problems (CMS, Medicare.gov).

1. How does the plan handle emergency and out-of-area care?

• Ensure emergency care is covered nationwide and verify rules for urgent care or emergencies while traveling.

1. Does the plan coordinate with other coverage I have?

• If you have employer coverage, retiree benefits, Medicaid or VA benefits, ask how those interact to avoid duplication or coverage gaps.

1. Are there utilization management rules that could impact care?

• Check for prior authorization, step therapy, or network requirements that could delay access to treatments you need.

1. How easy is member service and claims handling?

• Ask about how to find in-network providers, how to file appeals, availability of nurse lines or care managers, and whether they offer local plan representatives.

1. When can I change plans?

• Know enrollment windows: the Annual Enrollment Period (Oct 15–Dec 7) and the Medicare Advantage Open Enrollment Period (Jan 1–Mar 31) allow certain changes each year (Medicare.gov). Special Enrollment Periods apply for qualifying life events.

Step-by-step shopping process (practical approach)

1. List your must-haves: doctors, drugs, budget, and key benefits (dental, hearing, transportation).
2. Use the Medicare Plan Finder at Medicare.gov to create a short list of plans in your ZIP code (enter drugs and preferred providers for accurate results).
3. Compare total estimated annual costs, not just premiums—include copays, coinsurance and the worst-case out-of-pocket scenario.
4. Verify network participation by calling your provider’s office and checking the insurer’s provider directory. Provider directories can be out of date—ask your doctor if they accept the plan.
5. Read the Evidence of Coverage (EOC) summary for utilization rules, prior authorization and appeals procedures.
6. If you still have questions, contact a State Health Insurance Assistance Program (SHIP) counselor or a licensed agent. I recommend keeping notes and saving EOC pages for each plan you compare.

Real-world examples from practice

• A client with multiple chronic conditions chose a $0 premium plan but faced high specialist copays and restricted access to her cardiologist—total annual cost exceeded a higher-premium plan that had a broader network and included many meds on the preferred formulary. After switching, her annual out-of-pocket dropped by about $1,200.

• Another client saved $200 monthly by moving to a plan with better drug coverage (fewer specialty-tier meds and generous mail-order pricing) after mapping his exact medication list to the plan formulary.

These stories underline the importance of comparing costs for your own usage and checking formularies closely.

Common mistakes to avoid

• Choosing only by premium. Lower premiums can mean higher total costs or narrower networks.
• Not verifying the provider network. Online directories can be outdated—call your provider to confirm.
• Overlooking utilization rules. Prior authorizations or step therapy can delay or limit access to care.
• Forgetting to re-check plans each year. Benefits, networks and formularies can change at the start of each calendar year.

How to compare plans: a simple comparison table

Frequently asked questions (short answers)

Q: When can I change Medicare Advantage plans?
A: During the Annual Enrollment Period (Oct 15–Dec 7) you can switch plans. There’s also a Medicare Advantage Open Enrollment Period (Jan 1–Mar 31) to switch or return to Original Medicare in certain cases. Special Enrollment Periods may apply for qualifying events (Medicare.gov).

Q: Can I have Medicare Advantage and Medigap together?
A: No. Medigap is designed to work with Original Medicare. If you enroll in a Medicare Advantage plan, you generally cannot use a Medigap policy alongside it.

Q: What is a Medicare Star Rating?
A: CMS rates plans 1–5 stars on measures like customer service, preventive care, chronic disease management, and complaints. Higher stars often correlate to better performance and sometimes to plan bonuses (CMS).

Practical tips and pro-level strategies

• Build a “usage profile” for a year: estimate visits, tests and medication fills. Use that to compare total costs across plans rather than relying on premiums alone.
• If you travel frequently, prioritize plans with broad in-network coverage or strong out-of-area emergency rules.
• For high-cost drugs, check whether a plan offers specialty tiers with copayment caps or manufacturer copay programs.
• Keep a one-page summary of each plan you consider that lists the most important features for you (costs, providers, drugs, prior authorization rules).

How this fits into broader retirement planning

Medicare choices affect retirement cash flow and healthcare risk. For more on timing and financial impact of Medicare enrollment, see our guides on Medicare enrollment strategies and Medigap planning: Medicare Enrollment Strategies to Avoid Penalties and Gaps and Choosing the Right Medicare Supplement: A Beginner’s Guide. These resources walk through enrollment timing, penalties and how supplemental coverage coordinates with Medicare.

Sources and further reading

• Medicare Plan Finder and general Medicare guidance (Medicare.gov).
• Medicare Advantage program details and Star Ratings (Centers for Medicare & Medicaid Services – CMS).
• Research and analysis on Medicare Advantage trends (Kaiser Family Foundation).

Professional disclaimer

This article is educational and reflects general best practices as of 2025. It is not personalized insurance or legal advice. Contact a licensed insurance agent, certified counselor (SHIP), or your employer benefits administrator for guidance specific to your situation.

If you want, I can help you map your current medications and preferred providers to plans in a specific ZIP code—send the ZIP and a short list of medications (name, dose, frequency) and I’ll outline the next steps.