Choosing a Medicare Advantage plan comes down to five things: whether your doctors are in network, whether your prescriptions are covered, how much you’ll pay out of pocket, what extra benefits you need, and which plan type fits how you use healthcare. Getting these right matters more than chasing a low premium, because a $0-premium plan with the wrong network or formulary can cost you far more in the long run.
Decide if Medicare Advantage Is Right for You First
Before comparing Advantage plans against each other, make sure an Advantage plan is the right path at all. The alternative is sticking with Original Medicare (Parts A and B) and adding a Medigap supplement policy for cost protection, plus a standalone Part D drug plan. These two routes work very differently.
Medicare Advantage plans bundle everything into one plan, typically including drug coverage, and often cost less in monthly premiums (roughly $0 to $295 per month compared to $44 to $392 for Medigap). But Advantage plans require you to use a provider network, generally limit coverage to your local area, and come with more out-of-pocket costs when you actually use care. Medigap policies work with any doctor or hospital that accepts Medicare, function in any state, and shield you from most out-of-pocket expenses, but they carry higher premiums and never include prescription drug coverage.
If you travel frequently, split time between states, or have established relationships with specialists across a wide geographic area, Original Medicare with a Medigap supplement gives you more flexibility. If you want lower premiums, prefer a single plan that covers medical care and prescriptions together, and are comfortable using a local network, Medicare Advantage is worth exploring. One important timing note: if you don’t buy a Medigap policy during your initial enrollment window (the six months starting when you turn 65 and have both Parts A and B), insurers can require a health screening and may deny you coverage later.
Understand the Three Main Plan Types
Medicare Advantage plans come in three common structures, and the differences affect how freely you can see specialists and use out-of-network providers.
- HMO (Health Maintenance Organization): You choose a primary care doctor and need referrals to see specialists. You generally must stay within the plan’s provider network, and seeing an out-of-network provider means higher costs or no coverage at all. HMOs tend to have lower premiums and copays in exchange for less flexibility.
- PPO (Preferred Provider Organization): No primary care doctor required, no referrals needed for specialists. You can see out-of-network providers, though you’ll pay more than if you stay in network. PPOs give you the most flexibility within the Advantage world but typically charge higher premiums for it.
- PFFS (Private Fee-for-Service): No referrals required. The plan may or may not have a network. If it does, you can still go out of network as long as the provider accepts the plan’s payment terms. These plans are less common and can be unpredictable because provider acceptance isn’t guaranteed.
For most people, the choice comes down to HMO vs. PPO. If you’re comfortable with one health system and don’t mind getting referrals, an HMO’s lower costs make sense. If you want the freedom to see any specialist without asking permission first, or if you occasionally need care outside your area, a PPO is worth the higher premium.
Check That Your Doctors Are in Network
This is the single most important step, and the one most often rushed. A plan’s provider directory can be searched on the plan’s website, where you type in your doctor’s name to confirm participation. But online directories are frequently outdated. After checking the website, call your doctors directly and ask whether they participate in the specific plan you’re considering. Then verify with the plan itself that the doctor is listed in their current network.
This three-step check (directory, doctor’s office, plan) sounds tedious, but it prevents the unpleasant surprise of discovering mid-treatment that your cardiologist or oncologist isn’t actually covered. Pay particular attention to specialists you see regularly, not just your primary care doctor. If you’re in an HMO, also confirm that the hospitals and imaging centers your doctors use are in network, since a referral to an out-of-network facility could leave you with a large bill.
Make Sure Your Medications Are Covered
Nearly all Medicare Advantage plans include Part D prescription drug coverage, but each plan maintains its own formulary, which is the list of drugs the plan will cover. Not every plan covers every medication, and the cost you pay depends on which “tier” your drug falls into.
Most plans use a four-tier structure. Tier 1 covers generic drugs at the lowest copay. Tier 2 covers preferred brand-name drugs at a moderate copay. Tier 3 covers non-preferred brand-name drugs at a higher copay. The specialty tier sits at the top and carries the highest cost, reserved for expensive medications like certain biologics or cancer treatments. Moving from Tier 1 to the specialty tier can mean the difference between a $5 copay and hundreds of dollars per fill.
Before enrolling, look up every prescription you take on each plan’s formulary. All plans must cover at least two drugs per commonly prescribed category, and certain classes are protected by law, meaning plans must cover most drugs in those categories: cancer drugs, HIV/AIDS drugs, antidepressants, antipsychotics, anticonvulsants, and immunosuppressants for organ transplants. If a medication you take isn’t on a plan’s formulary, you may be able to request an exception, but there’s no guarantee it will be approved.
Compare Costs Beyond the Premium
A $0 monthly premium is appealing, but it tells you very little about what you’ll actually spend. The costs that matter most are copays for doctor visits and procedures, coinsurance for hospital stays, and the plan’s maximum out-of-pocket limit (often called MOOP).
Every Medicare Advantage plan is required to cap your annual out-of-pocket spending. In 2026, the federal ceiling for this cap is $9,250, though many plans set their limit lower. If you’re in a PPO, you’ll see two caps: one for in-network costs and a higher one for combined in-network and out-of-network spending. Once you hit the cap, the plan covers 100% of your costs for the rest of the year.
To estimate your real costs, think about how you used healthcare last year. How many specialist visits, how many prescriptions, any hospital stays or surgeries? Multiply those by the copays and coinsurance listed in each plan’s Summary of Benefits. A plan with a $20 premium but $50 specialist copays and 20% hospital coinsurance may cost you more annually than a plan with a $45 premium, $15 specialist copays, and lower coinsurance. The premium is just one line in your total healthcare budget.
Evaluate the Extra Benefits
Medicare Advantage plans frequently include supplemental benefits that Original Medicare doesn’t cover, and these can add real value depending on your needs. Over 99% of enrollees are in plans offering eye exams or glasses. About 98% have access to dental care, 95% to hearing exams or aids, and 94% to a fitness benefit like a gym membership.
Some plans go further with transportation to medical appointments (available to about 28% of individual plan enrollees), meal delivery after a hospital stay (70%), over-the-counter health product allowances (79%), and bathroom safety devices (32%). If you have multiple chronic conditions, Special Needs Plans (SNPs) offer significantly richer benefits in these areas: 80% of SNP enrollees get transportation, 82% get meal benefits, and 94% are offered food and produce benefits.
One catch: many of these supplemental benefits require prior authorization before you can use them. In 2025, 86% of enrollees in plans with comprehensive dental need prior approval before getting covered dental work. Over half need authorization for hearing and eye exams. Factor in not just whether a benefit exists on paper, but how easy it is to actually access.
Use Star Ratings as a Quality Check
Medicare rates every Advantage plan on a 1-to-5 star scale, with 5 being the best. These ratings are built from up to 43 individual measures for plans that include drug coverage. The measures span preventive care (cancer screenings, flu vaccines, diabetes management), customer experience (how easily you can get appointments, how members rate the plan’s quality), and administrative performance (how quickly the plan handles appeals, complaint rates, how many members leave the plan each year).
Plans with 4 or more stars generally deliver better care coordination, faster access to appointments, and more responsive customer service. They also receive bonus payments from Medicare, which often translates into lower premiums or richer benefits for members. You can check any plan’s star rating on Medicare.gov’s Plan Finder tool. A plan with great benefits on paper but a 2-star rating is telling you something about the actual experience of being enrolled there.
Know Your Enrollment Windows
You can join or switch Medicare Advantage plans during two periods each year. The Annual Enrollment Period runs from October 15 through December 7, and this is when most people make their choice. Any changes you make take effect January 1.
If you enroll in an Advantage plan and realize it’s not working, the Medicare Advantage Open Enrollment Period from January 1 through March 31 gives you one chance to switch to a different Advantage plan or drop back to Original Medicare with a standalone Part D drug plan. Outside these windows, you generally can’t make changes unless you qualify for a Special Enrollment Period due to a life event like moving or losing other coverage.
Plans can change their networks, formularies, premiums, and benefits every year. Even if you’re happy with your current plan, review the Annual Notice of Change that arrives each fall. A doctor you rely on may have left the network, a drug you take may have moved to a higher tier, or a competing plan may now offer better terms. Treating plan selection as an annual decision, not a one-time choice, is one of the most effective ways to keep your costs and coverage aligned with your actual needs.