How to check if your doctors and prescriptions are covered by a Medicare Advantage plan

The two questions that matter most when you choose a Medicare Advantage plan are simple: will I still be able to see my doctors, and will my prescriptions be covered at a cost I can afford? A plan can look good on paper and still leave out your cardiologist or put your medication on an expensive tier. Here’s how to check both before you enroll.

Step 1: Make your list

Before you look at any plan, write down:

• Doctors: each doctor’s full name, specialty, clinic or medical group, and the office address you go to
• Hospital: the hospital you’d want to use
• Prescriptions: each drug’s exact name, strength (for example, 20 mg), form (tablet, injection, inhaler) and how often you take it
• Pharmacy: the pharmacy you use, or whether you’d use mail order

The easiest way to get the drug details right is to copy them from your pill bottles or your pharmacy’s printout.

Step 2: Check your doctors

1. Search the plan’s provider directory. Every Medicare Advantage plan has an online directory. Search each doctor by name and make sure you’re looking at the directory for the right plan and the right year. One company can offer several plans with different networks.
2. Call the doctor’s office to confirm. Directories aren’t always up to date. Ask the office: “Are you in network for [the exact plan name] for next year?” Don’t just ask whether they “take Medicare.” A doctor can accept Original Medicare and still not be in a particular Medicare Advantage plan’s network.
3. Check the medical group and hospital. With many HMO plans, your doctor’s medical group matters, and some plans only work with certain groups or hospitals. Confirm your hospital is in network, too.
4. Check referrals. If it’s an HMO, ask whether you’ll need a referral to see your specialists.

Good to know: Medicare’s online Plan Finder lets you compare plans and drug costs, but it doesn’t confirm whether your doctors are in a plan’s network. Use the plan’s directory and call the office for that.

Step 3: Check your prescriptions

1. Enter your drugs in Medicare’s Plan Finder at Medicare.gov, or look up each one in the plan’s drug list (formulary). Plan Finder can estimate your total yearly drug costs for each plan at your pharmacy.
2. Check the exact drug and dose. A plan may cover one strength or form of a drug and not another, or cover the generic but not the brand name.
3. Look at the tier. The same drug can be on a low tier in one plan and a high tier in another, which can make a big difference in cost.
4. Look for restrictions. Next to each drug, the drug list shows whether it needs prior authorization (approval before the plan pays), step therapy (trying another drug first) or quantity limits.
5. Check your pharmacy. Many plans have preferred pharmacies with lower copays. Make sure yours is in network, and ideally preferred.
6. Compare the yearly total, not just the copay. Add the drug deductible and what you’d pay each month over a full year.

What if a drug isn’t covered?

• Ask your doctor whether a covered alternative would work for you.
• Ask for an exception. You or your doctor can ask the plan to cover a drug that isn’t on its list, or to lower its cost. Your doctor usually needs to explain why you need it.
• Transition supply: when you’re new to a plan, it generally must give you a temporary supply of a drug you were already taking while you and your doctor work out a long-term solution. Ask the plan how its transition process works.

Things can change during the year

Doctors can leave a plan’s network, and plans can make some changes to their drug lists during the year. Plans are generally required to tell you about these changes. If your doctor leaves the network or a drug you take changes, call me, and we’ll look at your options.

Let me check for you

This is exactly what I do for every person I help. Send me your list of doctors, prescriptions and pharmacy, and I’ll check each plan I represent before we talk about choosing one. That way you’re comparing the plans that actually fit you.

Send me your list of doctors and prescriptions, and I’ll check them for you.