Medicare FAQ 2026

Medicare Advantage (Part C) and Medigap (Medicare Supplement) are two completely different ways to get Medicare coverage beyond Original Medicare.

Medicare Advantage replaces Original Medicare entirely — it's an all-in-one plan sold by private insurers that covers hospital care, medical visits, and usually prescription drugs. These plans often have lower premiums but require you to use a specific network of doctors and hospitals. Most include extras like dental and vision.

Medigap works alongside Original Medicare. You keep Medicare Parts A and B and buy a Medigap policy to cover what Original Medicare doesn't pay — like copays, coinsurance, and deductibles. Medigap plans let you see any doctor who accepts Medicare, nationwide. The catch: Medigap doesn't include drug coverage, so you need a separate Part D plan. Premiums are generally higher than Medicare Advantage, but your out-of-pocket costs are more predictable.

The right choice depends on your health needs, doctor preferences, and financial situation. If you have a complex care team or travel frequently, Medigap's flexibility may be worth the premium. If you're generally healthy and cost is the priority, Medicare Advantage often delivers more value.

Compare plans for your situation →

Comparing Medicare plans in Las Vegas requires checking four things: which plans are available in your zip code, whether your doctors are in-network, whether your prescriptions are on the formulary, and what your total annual cost would be.

Las Vegas (Clark County) has dozens of Medicare Advantage plans available in 2026 from carriers like Humana, UnitedHealthcare, Aetna, Cigna, and Wellcare. The fastest way to compare is to enter your zip code, list your doctors, add your medications, and set a monthly budget. PlanPilot scores every plan in your area on doctor coverage (35%), drug coverage (30%), annual cost (25%), and star rating (10%), then surfaces your top 3 matches with a full breakdown.

Avoid comparing plans purely on premium — a $0-premium plan with a narrow network can cost far more if your specialist is out-of-network. The annual out-of-pocket maximum (MOOP) is equally important: in 2026, Medicare caps it at $9,350 for in-network costs. Some Las Vegas plans offer much lower MOOPs as a competitive benefit.

Find Las Vegas Medicare plans →

Medicare star ratings are annual performance scores assigned by CMS (Centers for Medicare & Medicaid Services) to every Medicare Advantage and Part D plan on a scale of 1 to 5 stars. Ratings measure plan quality across preventive care, managing chronic conditions, member experience, customer service, and drug safety.

Star ratings matter for three reasons. First, they're a proxy for plan quality — higher-rated plans tend to have better care coordination, fewer coverage disputes, and more responsive customer service. Second, CMS gives extra funding to 4+ star plans, which often gets passed on through lower premiums or better benefits. Third, 5-star plans allow a Special Enrollment Period — you can switch to a 5-star plan at any time during the year, not just during Annual Enrollment Period (Oct 15–Dec 7).

That said, a 3-star plan with your exact doctors and drugs in-network may be a better fit than a 5-star plan that doesn't cover your medications. PlanPilot weights star ratings at 10% of your match score — meaningful, but not the whole story. Your specific coverage fit drives the other 90%.

Try PlanPilot free →

Every Medicare Advantage and Part D plan publishes a formulary — a list of covered drugs organized by tier. Tier 1 is usually generic drugs with the lowest copays; Tier 5 or 6 covers specialty biologics with the highest cost-sharing.

To check coverage, you can search the plan's formulary on its website, use Medicare.gov's Plan Finder, or use PlanPilot. Enter your prescriptions and PlanPilot checks formulary coverage across all plans in your area — not just whether the drug is covered, but what your copay or coinsurance would be at each tier.

A few things to watch for: prior authorization (the plan must approve the drug before covering it), step therapy (you must try a cheaper drug first), and quantity limits (maximum supply per fill). If a drug you need isn't on a plan's formulary, you can request a formulary exception from the plan.

Always verify coverage annually — formularies change every January 1. A drug that was Tier 2 last year may be Tier 4 this year. PlanPilot uses 2026 formulary data for all comparisons.

Check your medications →

If your drug isn't covered by your plan's formulary, you have several options.

Request a formulary exception. Your doctor documents medical necessity, explaining why the non-covered drug is necessary and why covered alternatives won't work. Plans must respond to standard exception requests within 72 hours and expedited requests within 24 hours.

Ask about therapeutic alternatives. Your doctor may be able to prescribe a similar drug that IS on the formulary — same drug class, equivalent clinical result, much lower cost.

Check manufacturer assistance programs. Most pharmaceutical companies offer patient assistance programs or copay cards that can dramatically reduce your cost even without insurance coverage.

Switch plans at next enrollment. If a drug is critical to your health, formulary coverage should be your top filter at Annual Enrollment. PlanPilot identifies formulary gaps before you enroll so you don't get surprised mid-year.

The 2026 IRA drug price cap ($2,000 annual out-of-pocket maximum for Part D) now provides a meaningful ceiling even for expensive specialty drugs — a significant protection enacted in 2025.

Find plans that cover your drugs →

The Inflation Reduction Act authorized CMS to directly negotiate drug prices with manufacturers for the first time in Medicare's history. The first 10 negotiated drugs took effect January 1, 2026, with significant price reductions. These include:

Eliquis (blood thinner) — ~$79/month vs. ~$520 retail · Jardiance (diabetes/heart failure) · Xarelto (blood thinner) · Januvia (diabetes) · Farxiga (diabetes/heart failure/kidney disease) · Entresto (heart failure) · Enbrel (arthritis/psoriasis) · Imbruvica (blood cancer) · Stelara (psoriasis/Crohn's) · Fiasp/NovoLog insulin products.

The negotiated prices apply to Part D plans — you'll pay your plan's cost-sharing structure, but the base price is now lower. Additionally, the $2,000 annual out-of-pocket cap on Part D (effective 2025) dramatically reduces exposure for anyone on expensive specialty drugs.

If you take any of these medications, double-check how your specific plan covers them for 2026 — the negotiated prices create new cost dynamics across plan tiers.

Compare 2026 drug coverage →

Checking whether your doctor is in-network for a Medicare Advantage plan requires looking at the plan's provider directory, not Medicare.gov. A doctor who accepts Original Medicare may NOT be in-network for a specific Advantage plan — these are separate lists.

Each plan publishes an online provider directory searchable by doctor name, specialty, or zip code. The most accurate method: search the plan's website directly or call member services and ask to verify your specific physician.

Important: In-network status changes annually. Your doctor could drop a plan (or a plan could drop your doctor) at renewal. Always re-verify at the start of each plan year, especially after the Annual Enrollment Period ends December 7.

PlanPilot lets you enter your doctors by name and checks in-network status across all plans in your zip code — weighted at 35% of your match score, because having your specialists covered is typically the most impactful cost factor. If your doctor is out-of-network in an HMO plan, services may not be covered at all — not just at a higher rate.

Check your doctors →

If your doctor leaves your Medicare Advantage network mid-year, your options depend on your plan type.

HMO plans: You generally won't have coverage for that doctor's services, except emergencies. You'll need to find a new in-network doctor or switch plans.

PPO plans: You can still see the doctor out-of-network, but at the higher out-of-network cost-sharing rate.

Continuity of care protection: If you're in an active course of treatment (chemotherapy, pregnancy, post-surgery recovery), you may have the right to continue seeing your provider for a transitional period — typically 90 days — at in-network rates even after they leave the network. This is a federal CMS requirement.

You may also qualify for a Special Enrollment Period if your plan substantially reduces its service area or benefits. To reduce the risk: prefer PPO plans if your doctors switch networks frequently, and call to verify in-network status rather than relying solely on the online directory, which can lag behind real-time changes by several weeks.

Find plans with broad networks →

These three terms represent fundamentally different types of Medicare spending.

Premium is what you pay every month just to have coverage — due regardless of whether you use healthcare. Many Medicare Advantage plans have $0 premiums, though you still pay your Part B premium ($185/month in 2026). Think of it as your monthly membership fee.

Deductible is what you pay out-of-pocket before the plan starts sharing costs. A $500 deductible means you pay the first $500 in medical bills yourself. Not all Medicare Advantage plans have deductibles — many are $0.

MOOP (Maximum Out-of-Pocket) is the annual ceiling on your cost-sharing exposure. Once you've paid this amount in copays and coinsurance, the plan covers 100% of in-network costs for the rest of the year. In 2026, the Medicare-mandated MOOP cap for in-network costs is $9,350. Some plans set lower MOOPs as a competitive benefit.

The MOOP is arguably the most important number for anyone with significant health needs — it's your worst-case financial scenario. A plan with a higher premium but lower MOOP may cost you less if you use a lot of healthcare.

Estimate your total annual cost →

Estimating total annual Medicare costs requires adding four buckets.

1. Premiums: Monthly plan premium × 12, plus your Medicare Part B premium ($185/month in 2026 × 12 = $2,220 annually). This is your fixed baseline cost.

2. Drug costs: For each prescription, find the plan's tier and copay, multiply by how many fills you'll need in a year. A Tier 3 drug at $45/fill × 12 = $540/year.

3. Medical cost-sharing: Estimate from last year's utilization — primary care visits, specialist visits, lab tests, imaging, hospital days. Multiply each by the plan's copay for that service type.

4. Extras: Check whether the plan covers things you currently pay for separately — dental, vision, hearing, gym membership. Factor in the offset.

Most people underestimate total costs by focusing only on the premium. A $0-premium plan can cost thousands more than a $100/month plan if your prescriptions are on a higher tier or your MOOP is higher. PlanPilot automates this calculation — enter your doctors, drugs, and budget and it estimates annual total cost across all plans in your area.

Calculate your total cost →

PlanPilot uses a weighted scoring algorithm to rank every Medicare Advantage plan in your zip code based on your specific profile. The matching engine scores four factors:

Doctor coverage (35%) — whether your listed doctors are in-network for each plan. Drug coverage (30%) — whether your prescriptions are on the formulary and your estimated annual drug cost. Annual cost (25%) — estimated total out-of-pocket spending including premiums, copays, and cost-sharing. Star rating (10%) — CMS's quality score for the plan.

Every plan receives a composite score from 0–100. PlanPilot surfaces your top 3 matches with a full breakdown — which doctors are covered, which drugs are on formulary and at what tier, the estimated annual cost, and the plan's star rating. The whole process takes under 60 seconds.

You enter your zip code (Step 1), add your doctors by name (Step 2), add your prescriptions with dosage (Step 3), and set your monthly budget (Step 4). Optionally leave your email and we'll send your results so you can reference them during enrollment.

Try PlanPilot now →

Yes, PlanPilot is completely free. No account required, no credit card, no sales pitch.

You enter your zip code, doctors, prescriptions, and monthly budget. PlanPilot scores every Medicare Advantage plan in your area and shows your top 3 matches in under 60 seconds. We don't receive commissions from insurers and we don't sell your information.

If you want help enrolling in a plan after reviewing your matches, we can connect you with a licensed independent Medicare broker — but that's entirely optional.

PlanPilot is most useful during the Annual Enrollment Period (October 15 – December 7), when you can switch Medicare Advantage plans for the following year, and during the Medicare Advantage Open Enrollment Period (January 1 – March 31), when you can make one plan change. That said, you can use PlanPilot any time to understand your options.

Find my best plan →

Both PlanPilot and Medicare.gov Plan Finder help you compare Medicare plans, but they take fundamentally different approaches.

Medicare.gov Plan Finder is the official CMS tool — comprehensive and authoritative, but designed to show you all plans with filtering options. You do the comparison work yourself, filtering by plan type, premium range, or drug coverage. It's powerful but requires time and Medicare knowledge to use effectively.

PlanPilot is designed for a different goal: tell us your specific situation and we rank plans for you. Instead of showing you a table of 40+ plans to evaluate, PlanPilot scores every plan against your exact doctors, prescriptions, and budget — then gives you your top 3 with a clear explanation of why each ranked where it did.

Use PlanPilot when you want a recommendation, not a spreadsheet. Use Medicare.gov Plan Finder when you want to do exhaustive research across all available plans. Ideally, use PlanPilot to identify your top matches, then verify those specific plans on Medicare.gov before enrolling.

Get your top 3 matches →