One benefit of having a Medicare Advantage plan is that you have the option to choose something new each year — and there are plenty of plans available, ranging from $0 premiums to more expensive offerings. You want to make sure, though, that your plan does more than give you a free gym membership. It should cover your doctors and medications with out-of-pocket costs you can afford.
Open Enrollment (Oct. 1 through Dec. 7) is the time to look over your current plan, make sure it’s still available, and see if it will fit your budget and health needs next year. The best way to choose the right Medicare plan is to take some time with a pen, healthcare receipts, and online patient portals. This information, and about 30 minutes of your time, can build a Medicare plan comparison checklist that will guide you to your next best health plan.
Take out a piece of paper and a pencil and follow along with each step.
Step 1: Export your 12-month utilization history
To know what kind of coverage you need from your Medicare plan, you should understand your healthcare utilization. One way to do that is to track the services and medications you took over the past year. This information gives you a pretty good gauge for what to anticipate for next year.
- First, log into your patient portals for all your doctors or health systems where you received care. Download or take note of all your visits and recurring therapies you received last year.
- Second, log into your pharmacy portal(s). Take down the name, exact dosage, and frequency of all your medications.
Performing these steps online and making notes is the best way to ensure you include all your healthcare usage. Don’t rely on your memory. Simple things, like maintenance medications, are easy to leave off your list and cause unexpected costs down the line.
Step 2: Identify nonnegotiable providers and planned care
Like most Medicare beneficiaries, you probably have a handful of doctors and other service providers you trust. It may be the primary care doctor you’ve had for 20 years or a chiropractor who keeps your hips in tip-top shape. Either way, some care providers are “must-keep.” These include:
- Primary care doctors,
- Cardiologists,
- Rheumatologists,
- Oncologists,
- Surgical centers,
- Pharmacies,
- Physical therapists,
- Your hospital system.
Care providers you might consider changing when you move to a new plan include:
- Routine urgent care,
- Standard lab providers,
- Stand-alone imaging centers.
Review all your providers and write down ones you would most like to keep and others who you wouldn’t mind switching if your plan doesn’t cover them all.
Planned medical care
Medical emergencies can’t be anticipated. But much of the care you do get is planned well in advance. If your doctor has talked to you about a potential surgery, or you already have one on the books, make sure to document it in your audit. All kinds of procedures – including cataract surgery, a knee replacement, or hernia repair – can have a major impact on your out-of-pocket healthcare expenses.
Step 3: Calculate “worst-case” financial exposure
Whether you’re already on Medicare or will be new this year, you’ve likely seen advertisements for $0-premium plans. They can be great for some Medicare beneficiaries. But it’s important to understand that if you aren’t paying upfront in premiums, you’ll be paying more out-of-pocket as you use healthcare services.
Medicare Advantage plans do offer cost protection, though. The maximum out-of-pocket (MOOP) limit for Medicare Advantage plans allowed in 2026 is $9,250, and $13,900 if you use both in-network and out-of-network providers. The average MOOP for 2026 was $5,421 for in-network services and $9,825 for both kinds of providers.
Even with a MOOP limit, your costs could be high if you have one or more chronic conditions. Each specialist visit you have comes with a copay of about $50, depending on your specific plan. If you have a flare-up and need a hospital stay, most plans have daily copays, which can be between $200 and $500. Even a short three-day visit can add up to $750 to $1,500 on top of your other costs for the year. One way to save money is to enroll in a plan with a $25 monthly premium (the average for 2026 is $14) and lower copays and coinsurance.
If you think you may be seeing a lot of specialists or have one or more hospital visits per year, make note of that. This will help you tally up your potential expenses based on a plan’s out-of-pocket costs.
Step 4: Side-by-side plan comparisons
Once you have all your health information on hand, it’s time to compare Medicare Advantage plans. You can do this by using our 2027 Plan Finder or Medicare.gov’s plan finder. The SmartMatch plan finder lets you compare up to three plans side-by-side. The tool gives you details including your monthly premium, out-of-pocket maximum, and information on Part D prescription drug coverage. If you have an idea of how many visits you’ll make to the doctor and your potential drug expenses, you can look at the copays, coinsurance, and deductibles to calculate your potential Medicare out-of-pocket costs for 2027 with various plans.
The tool will also let you know if a Medicare Advantage plan is an HMO (health maintenance organization) or a PPO (preferred provider organization). This is an important component of your plan because it indicates how your plan sets provider networks, out-of-pocket costs, and referrals.
With an HMO:
- You usually pick a primary care provider who manages all your care,
- There are usually fewer doctors and hospitals in-network on a plan,
- It may not cover doctors you see out-of-network,
- You often need a referral for the plan to pay for specialty care.
With a PPO:
- You typically don’t need a referral for the plan to cover a specialist visit,
- The provider networks are often larger,
- The plan usually covers some out-of-network care (though you’ll likely pay more for these services than for in-network providers).
Note: It’s important to verify that your doctors, health systems, and pharmacies are in-network for any plan you choose. Provider directories update frequently, so you’ll want to check with the plan before enrolling.
Step 5: Audit drug formularies and pharmacy tiers
To explain Medicare drug formulary tiers, a plan’s drug formulary is the list of prescription drugs it covers. Most plans offer a range of medications so beneficiaries’ needs are covered, but the drugs are classified into what is known as tiers. These tiers, or levels, dictate how much you pay for the drug. The lower the level (Tier 1), the lower the cost tends to be for medications. Your out-of-pocket costs generally increase as the levels get higher, with Tier 5 being the most expensive. The tiers generally look like this:
- Tier 1 – generic drugs,
- Tier 2 – preferred, brand-name drugs,
- Tier 3 – nonpreferred, brand-name drugs,
- Tiers 4 and 5 – very high-cost and specialty drugs.
Writing down a list of prescription drugs you take will help you search for the tiers they are in. You should also take note of how a plan separates its pharmacy network. Many Medicare Advantage plans have two types of in-network pharmacy coverage: Preferred and standard. While both are in-network, you pay less out of pocket when you use a preferred pharmacy than with a standard one. Preferred pharmacies typically agree to charge less for medications because the plan agrees to direct more patients toward those pharmacies. These preferred pharmacies are often national chains and regional stores.
Another aspect of plans to watch out for is utilization management restrictions. These are particularly important if you have one or more chronic conditions that require medication. Plans put utilization management tools in place to ensure medications are cost-effective for the plan. Typical kinds of utilization management include:
- Prior authorization, which means a health plan must approve the drug before it pays for it.
- Step therapy, which requires you to use lower-cost or generic drugs before moving up to more expensive or brand-name medications.
- Quantity limits, which require pharmacists to dispense only a certain amount (like 30 days’ worth) of medication at a time.
Utilization management can help ensure drugs are being used safely, but they also allow the plan to delay or deny your medications of choice.
Turn your audit into action
After about 30 minutes, you should have a completed audit sheet and be ready to sign up for your next Medicare Advantage plan. You should know your essential doctors and pharmacies and verify which plans cover your medications and at what tier. Knowing what your potential healthcare services for the year will be, and how they are covered by different plans, can help you gauge your possible healthcare costs. If you still have questions about which Medicare Advantage plan is best for you after your audit, a licensed SmartMatch agent can help guide you through the enrollment process.
