How to Choose the Right Medicare Advantage Plan

Start with the Basics—Does It Fit You?

It’s important to pick a plan that fits you in several key areas—and not just on paper. We’re talking about how the plan works in real life, for your real doctors, prescriptions, and health needs.

Let’s start with the first thing most people care about: your doctor. Which plan covers all your doctors? Ask yourself how important are your current doctors? Am I willing to pay more out of pocket just to see them? Are there other benefits or costs that are more important to you than your doctor(s)? For some, their primary doctor is their most important provider; but for others, it is their specialist—like a cardiologist, endocrinologist, or pain management provider. This is an important step that needs to be addressed before even looking at plans or benefits.

Checking your doctor’s network status is step one. It seems basic, but you’d be surprised how many people pick a plan without confirming this. And then they get stuck later, having to switch doctors or pay more to keep the one they’ve trusted for years.

HMO vs. PPO – What’s the Difference?

Medicare Advantage plans are set up with a network of providers. There are different types of networks; there are HMO and PPO and another that’s kind of a combination called a HMO-POS.

• HMO (Health Maintenance Organization): These plans require you to use a specific network of doctors and hospitals. Most of the time, you need to choose a primary care provider (PCP), and that doctor becomes your “gatekeeper.” That means you’ll need a referral to see a specialist. Some people don’t mind this—it helps keep care organized—but others find it restrictive.

   

• PPO (Preferred Provider Organization): PPO plans give you more flexibility. You can see doctors both in-network and out-of-network, although you’ll usually pay more for out-of-network visits. You don’t need a referral to see a specialist, which can be a huge plus if you have multiple conditions or ongoing specialty care.

   

• HMO-POS (Point Of Service): These types of plans have in-network providers at a lower rate, and the ‘Point Of Service’ is an option that some benefits are available out of network. How that differs from a PPO plan, where all the benefits are available both in and out of network, a POS plan can designate specific benefits that are available in or out, and specific benefits that must be in-network and not covered at all out of network.

   

• PFFS (Private Fee For Service): This is a unique plan where there is no specific network. Every time you use the benefits, the provider or organization decides to agree or to not agree to the terms and conditions of the plan.

   

Generally speaking, HMO plans are going to save you more and PPO plans will cost you more; HMO you have to stay in-network (with exception of emergency and urgent care) and PPO plans you can go in or out of network. That decision can only be made when you know the HMO network. Some HMO networks are more broad than the network of the PPO. Many HMO plans are open access and do not require referrals. Some HMO networks include a national network. And it’s also true that some HMO plans can be tight and constricting.

This is where an independent insurance agency in Green Bay WI is key; the agent can help you understand and discover the details of the HMO and PPO network and costs and help you determine which will fit your budget and needs.

Don’t Forget the Other Providers

While checking the network, in addition to doctors, also check other services and providers like:

• Hospitals

   

• Clinics

   

• Urgent care centers

   

• Labs

   

• Durable medical equipment (DME) suppliers

   

• Pharmacies

   

If any of these are out-of-network, your costs could skyrocket or you may not be able to use them at all.

Do I Need a Referral or Prior Authorization?

As I mentioned above, checking if the plan requires referrals for specialist visits is important. This is different than prior authorizations. Prior authorizations are when your doctor has to get approval from the insurance company before conducting a procedure, test, or prescription. Referrals are permission for you to visit a specialist. Some plans require referrals and some do not.

Pharmacy Benefits: Don’t Overlook This

The next factor that’s key to looking at in choosing a Medicare Advantage plan is your prescriptions.

Check that the plan has your pharmacy “in-network”—and even better, as a preferred pharmacy. What’s the difference?

• Preferred pharmacies usually have lower prices for the same drugs

   

• Standard pharmacies are still in-network, but often more expensive

   

Many people assume all pharmacies cost the same with their plan. They don’t. Getting your prescriptions at a standard instead of a preferred pharmacy could save you $50–$100 a month—or more.

How to Check Your Drugs and Coverage

Next, check the formulary of covered prescriptions. Type in every medication you take, exactly how you take it:

• Name of the drug

   

• Brand or generic

   

• Strength (e.g., 20mg)

   

• Form (tablet, capsule, liquid, etc.)

   

• Frequency (once a day, as needed, etc.)

   

From there, the plan will show you:

• Which tier your drug falls into (tiers affect pricing)

   

• Whether there’s a deductible to meet

   

• Any co-pays or coinsurance costs

   

• If you need prior authorization

   

• If there are quantity limits or step therapy rules

   

Let’s quickly define those:

• Prior Authorization: When you need to get approval before the plan pays for the drug.

   

• Step Therapy: You must try a cheaper drug first and fail it before the plan covers the one you want.

   

• Quantity Limits: The plan covers a limited amount of that drug per month.

   

All of these can impact your ability to get your medication quickly and affordably. This is why checking your drug list matters so much—especially if you’re on maintenance medications you take every month.

Added Benefits That Make a Difference

After you’ve checked your doctors and prescriptions, look at the added benefits. Medicare Advantage plans often include extras that Original Medicare doesn’t.

These can include:

• Dental cleanings, x-rays, and major work like crowns or dentures

   

• Vision benefits for exams, glasses, or contacts

   

• Hearing exams and hearing aids

   

• Over-the-counter (OTC) benefits

   

• Transportation to medical appointments

   

• Part B premium rebates (also known as givebacks)

   

• Meal delivery or grocery benefits

   

• Fitness memberships (like SilverSneakers)

   

Are you going to use every single benefit? Probably not. But even if you only use dental, vision, and an OTC card, that could save you hundreds of dollars per year.

When comparing plans, don’t just look at what sounds nice—look at what you’ll realistically use. And ask your independent insurance agent to help walk you through the pros and cons.

Why Work with an Independent Agent?

This is where the help of someone local makes all the difference. An independent insurance agent (like our team at OnMedicare Insurance) has access to plans from multiple insurance companies. We aren’t here to push one plan over another—we’re here to figure out what’s right for you.

Because here’s the truth: the best Medicare Advantage plan isn’t the one with the longest brochure or the fanciest TV commercial. It’s the one that works best for you, with your doctors, your prescriptions, your budget, and your health goals.

At OnMedicare Insurance Agency, we look at the competitive plans in your specific county and zip code. We don’t guess—we compare. We help you look at the whole picture—because sometimes, a plan that looks amazing on benefits ends up being too restrictive on your doctor network or too high on prescription costs.

Let us help you sort through all the noise and simplify the process.