Doctors, Hospitals and Other Health Care Providers
- Will I be able to use my doctors? Are they in the plan’s network?
- Do doctors and providers I want to see in the future take new patients who have this plan?
- If providers aren’t in the network, will the health plan still cover my visits if I choose to see them?
- Do my doctors recommend joining this plan?
- Which specialists, hospitals, home health agencies and skilled nursing facilities are in the plan’s network?
Access to Health Care
- Who can I choose as my Primary Care Physician (PCP)?
- Does my doctor need to get approval from the plan to admit me to a hospital?
- Do I need a referral from my PCP to see a specialist?
- What extra benefits does the plan offer? What rules do I have to follow to get them?
- Dental services
- Vision care
- Hearing aids
- Does the plan cover outpatient prescription drugs?
- Are my prescription drugs on the plan’s formulary (list of covered drugs)?
- Does the plan require that I get prior authorization before my prescription will be covered, or impose other restrictions, like limiting the quantity or requiring that I try a cheaper medication before it will cover a more expensive one?
- Do I have to pay a deductible before the plan will cover my drugs?
- How much will I have to pay for brand-name drugs? How much for generic drugs?
- What will I pay for my drugs during the coverage gap?
- Will I be able to use my pharmacy? Can I get my drugs through mail order?
- Will the plan cover my prescriptions when I travel?
- How much is the Medicare Advantage Plan’s monthly premium?
- Will I pay a higher premium because of my income? (Since 2011, individuals with yearly income above $85,000 and couples with yearly income above $170,000 pay more for both Part B and Part D.)
- What is the annual out-of-pocket maximum? (After you spend a certain amount, your care will be free or very low cost).
- Note: PPOs have different out-of-pocket limits for in-network and out-of-network care. If you’re in a PPO, you should find out what the different out-of-pocket limits are for in-network and out-of-network care.
- How much will I have to pay out of pocket before coverage starts (what is the deductible)?
- How much is my copayment for a visit with my PCP or a visit with a specialist?
- How much will I pay if I use a non-network doctor or hospital?
- Are there higher copays for certain types of care, such as hospital stays or home health care?
- What service area does the plan cover?
- What kind of coverage do I have if I travel outside of the service area?
Coordination of Benefits
- How does the plan work with my current coverage?
- If I join, would I lose my retiree/employer health coverage?