Comparing Medicare Advantage plans means looking beyond the monthly premium and evaluating network restrictions, drug coverage, out-of-pocket limits, and supplemental benefits side by side. The average enrollment-weighted premium across all Medicare Advantage plans in 2025 is just $13 per month, and many plans advertise $0 premiums, which makes it tempting to choose on price alone. But the real cost differences show up in copays, provider access, and what happens when you need expensive care.
Start With the Plan Type: HMO vs. PPO
The single biggest structural difference between Medicare Advantage plans is whether they’re an HMO or a PPO. This determines how much flexibility you have in choosing doctors and whether you need referrals.
HMO plans require you to choose an in-network primary care physician and get referrals before seeing specialists. If you go out of network for anything other than emergencies, urgent care while traveling, or dialysis, you’ll typically pay 100% of the cost yourself. PPO plans don’t require you to pick a primary care doctor or get referrals for specialists. You can see out-of-network providers, though you’ll pay more than you would for in-network care.
If you travel frequently, split time between two states, or have specialists you’re not willing to give up, a PPO gives you more room. If you’re comfortable staying within a local network and want lower copays, an HMO will usually cost less for the same services.
Check Whether Your Doctors Are In Network
Every Medicare Advantage plan maintains a network of doctors, hospitals, and other providers. Before comparing anything else, verify that your current doctors and preferred hospital are in each plan’s network. Most plans let you search their provider directory on their website, and the Medicare Plan Finder at Medicare.gov also shows network information by ZIP code.
Don’t assume that because a plan is available in your area, your doctors participate. Networks vary dramatically even among plans from the same insurer. And keep in mind that networks can change from year to year, so a plan that included your cardiologist last year might not include them next year.
Compare Out-of-Pocket Limits, Not Just Premiums
One of the biggest advantages of Medicare Advantage over Original Medicare is the mandatory annual cap on out-of-pocket spending. Original Medicare has no yearly limit on what you pay unless you buy a supplemental Medigap policy. Medicare Advantage plans set a maximum: once you hit it, the plan covers 100% of your Medicare-covered services for the rest of the year.
These caps vary widely between plans. Some set the limit around $3,000 to $4,000 for in-network services, while others go as high as $8,000 or more. PPO plans often have separate, higher limits for combined in-network and out-of-network spending. When comparing plans, look at the out-of-pocket maximum as your worst-case scenario for the year. A plan with a $0 premium but a $9,000 out-of-pocket cap could cost you far more than a plan with a $50 monthly premium and a $4,000 cap if you end up needing surgery or cancer treatment.
Also compare the copays and coinsurance for the services you actually use. What does each plan charge for a primary care visit? A specialist visit? An MRI? A three-day hospital stay? These per-service costs are where most of your spending happens in a typical year.
Look Closely at Drug Coverage
Most Medicare Advantage plans bundle prescription drug coverage, so you won’t need a separate Part D plan. But the drugs covered and what you pay for them differ significantly from plan to plan.
Every plan maintains a formulary, which is its list of covered medications. Plans organize drugs into tiers, and your cost depends on which tier your medication falls into. The typical structure looks like this:
- Tier 1 (lowest cost): most generic drugs
- Tier 2 (medium cost): preferred brand-name drugs
- Tier 3 (higher cost): non-preferred brand-name drugs
- Specialty tier (highest cost): very expensive medications
A drug that sits in Tier 2 on one plan might land in Tier 3 on another, meaning you’d pay significantly more for the exact same medication. If you take ongoing prescriptions, check each plan’s formulary to confirm your drugs are covered and note which tier they’re on. If a specific drug isn’t on the formulary, a similar alternative usually is, but switching medications isn’t always straightforward.
The Medicare Plan Finder lets you enter your current medications and preferred pharmacy to estimate your total annual drug costs under each plan. This is one of the most useful features of the tool and worth the few minutes it takes to set up.
Evaluate Supplemental Benefits
Medicare Advantage plans often include benefits that Original Medicare doesn’t cover at all. The most common extras are dental, vision, and hearing coverage. Some plans also offer fitness program memberships, transportation to medical appointments, meal delivery after a hospital stay, and over-the-counter health product allowances.
These benefits vary enormously in their actual value. One plan might cover two dental cleanings and an eye exam per year. Another might offer a $1,000 annual dental allowance that covers crowns and dentures. If you need hearing aids, which can cost thousands of dollars, a plan with robust hearing benefits could save you more than any difference in monthly premiums. Look at the specific dollar amounts and coverage limits rather than just checking whether a benefit category exists.
Understand Prior Authorization Requirements
This is one of the most overlooked differences between plans and one that can directly affect your care. Prior authorization means the plan must approve a service before you receive it, or they may not pay for it. Original Medicare rarely requires prior authorization, but 80% of Medicare Advantage enrollees are in plans that require it for at least one Medicare-covered service.
The services most commonly requiring prior authorization include durable medical equipment (like wheelchairs or CPAP machines), certain injectable drugs, skilled nursing facility stays, and inpatient hospital admissions. About 70% of enrollees are in plans requiring approval for all of these. Roughly 60% are in plans that require prior authorization for ambulance services, home health care, procedures, and lab tests. More than half are in plans that require it for mental health services.
Prior authorization can delay care and sometimes results in denials. Federal investigators have found that some plans deny care inappropriately at relatively high rates. When comparing plans, check whether the services you’re likely to need require prior authorization. Plans are required to disclose this information, and it’s increasingly available through Medicare’s comparison tools.
Use Star Ratings as a Starting Filter
CMS rates Medicare Advantage plans on a one-to-five-star scale based on dozens of quality and performance measures, covering areas like how well the plan manages chronic conditions, member satisfaction, complaint rates, and customer service. These ratings appear on the Medicare Plan Finder during enrollment season.
Plans with five stars earn a “high performing” icon, while consistently low-rated plans get flagged with a low-performing indicator. In 2026, 21 contracts earned five-star status. Star ratings aren’t a perfect measure of whether a plan will work for you personally, but they’re a reasonable way to filter out plans with persistent quality problems. Plans rated below three stars are generally worth scrutinizing more carefully.
How to Run Your Comparison
The most efficient way to compare plans is through the Medicare Plan Finder at Medicare.gov. Enter your ZIP code, add your current prescriptions and preferred pharmacies, and the tool will show you estimated total annual costs for each available plan. It factors in premiums, drug costs, and deductibles to give you a more complete cost picture than any single number can.
Once you’ve narrowed your options to two or three plans, dig into the details that the tool summarizes. Pull up each plan’s full Summary of Benefits to compare copays for the services you use most. Check the provider directory for your doctors. Review the formulary for your medications and note the tiers. Look at the out-of-pocket maximum and consider what a bad health year would cost you under each plan.
Open Enrollment runs from October 15 through December 7 each year. This is when you can join, switch, or drop a Medicare Advantage plan for the following year. Plans can change their benefits, networks, and costs annually, so even if you’re happy with your current plan, it’s worth re-comparing each fall to make sure it still fits.