15 questions to ask before choosing a Medicare plan — covers medications, doctors, costs, and extra benefits. Free to download and print.
What's inside
Most people pick their Medicare plan based on the monthly premium. That's a mistake. Four sections — 15 total questions — to compare what actually matters.
1
Medication Coverage — 5 questions
Are all my prescriptions on this plan's formulary?Look up every drug you take on the plan's formulary search. A plan that covers 4 of your 5 medications is not a "good" plan if medication #5 costs $400/month.
What tier are my drugs placed on?Same drug, different tier = very different monthly cost. Tier 1 generics run $0–$10. Tier 4–5 specialty drugs can exceed $100/month even with coverage. Find the tier, then calculate your actual cost share.
Does this plan require prior authorization for any of my medications?Prior auth means the plan must approve your prescription before covering it — adding delays and paperwork. Brand-name drugs and newer medications (GLP-1s, certain biologics) are most likely to require prior auth.
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Medicare Plan Comparison Checklist
1
Medication Coverage — 5 questions
Are all my prescriptions on this plan's formulary?Look up every drug you take on the plan's formulary search. A plan that covers 4 of your 5 medications is not a "good" plan if medication #5 costs $400/month.
What tier are my drugs placed on?Same drug, different tier = very different monthly cost. Tier 1 generics run $0–$10. Tier 4–5 specialty drugs can exceed $100/month even with coverage. Find the tier, then calculate your actual cost share.
Does this plan require prior authorization for any of my medications?Prior auth means the plan must approve your prescription before covering it — adding delays and paperwork. Brand-name drugs and newer medications (GLP-1s, certain biologics) are most likely to require prior auth.
Are step therapy requirements in place for any of my drugs?Step therapy means you must try a cheaper alternative before the plan covers your preferred medication. Ask specifically about any specialty drug you're currently taking — switching may not be medically appropriate.
What is the plan's drug deductible, and does it apply to my medications?Many plans have a separate drug deductible (up to $590 in 2026) that applies before coverage kicks in. Some plans exempt Tier 1–2 drugs. Calculate how many months you'd be paying full cost before hitting the deductible.
2
Doctor Access — 3 questions
Is my primary care doctor in this plan's network?Use the plan's provider directory to confirm — don't assume. Networks change every year, and a doctor listed as "in-network" during your search may not be by January 1. Call the office to double-check.
Are my specialists (cardiologist, endocrinologist, oncologist, etc.) in-network?Specialist visits are where network gaps hurt most. An out-of-network specialist on an HMO plan can cost 3–10x more than in-network. Verify each specialist you see regularly, not just your primary care doctor.
Does this plan require referrals for specialist visits?HMO plans typically require a referral from your primary care doctor before you can see a specialist. PPO plans generally do not. If you see multiple specialists regularly, a PPO or PFFS plan offers more flexibility — at a higher premium.
3
Cost Comparison — 4 questions
What is the plan's maximum out-of-pocket (MOOP) limit?This is the most money you'll pay for covered services in a year. In 2026, the cap is $9,350 for in-network services. A low premium plan with a $9,000 MOOP can cost more than a $80/month plan with a $5,000 MOOP if you have significant health needs.
What are the copays or coinsurance for the services I use most?Look beyond the deductible — what do you pay per primary care visit, specialist visit, urgent care, and lab work? If you see your doctors 6+ times per year, high copays add up faster than a monthly premium difference.
Have I estimated my total annual cost — not just the monthly premium?Add: (monthly premium × 12) + drug costs + expected copays + estimated deductible usage. A $0 premium plan can easily cost $3,000+ more annually than a $60/month plan depending on your usage pattern.
What does this plan cost if I have a major health event (hospitalization, surgery)?Review the inpatient hospital cost sharing. Some plans have low daily copays ($0–$300/day for days 1–6). Others have coinsurance that kicks in. A week-long hospital stay can easily cost $1,500–$5,000 in cost sharing on the wrong plan.
4
Extra Benefits — 3 questions
Does this plan include dental, vision, or hearing coverage?Original Medicare doesn't cover routine dental, vision, or hearing. Many Medicare Advantage plans include basic benefits — but "included" varies from comprehensive coverage ($1,500/year dental allowance) to a basic discount program. Read the details, not the marketing copy.
Are fitness benefits, transportation, or OTC allowances meaningful for my situation?Some plans offer SilverSneakers gym memberships, non-emergency medical transportation, or OTC allowances ($100–$500/quarter). These are real value — if you'd actually use them. Don't let a $200 OTC allowance distract you from a drug coverage gap.
How does this plan's care management or chronic condition support work?Medicare Advantage plans targeting patients with diabetes, heart disease, or COPD sometimes offer disease management programs with care coordinators, free supplies, or reduced cost-sharing for condition-specific services. Ask if these apply to your conditions.
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