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

Prescription Drugs

  • 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? (Starting in 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?

Service Area

  • 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?