Picking a Medicare plan is one of the biggest financial decisions you will make this year. The right plan depends on your doctors, your drugs, and your specific situation. The wrong plan can cost you thousands and limit your care for years. Here are 10 questions that get you to the right answer.
1. Are my doctors in the network?
This is the most important question, period. If your favorite doctor is not in the plan's network, every visit will cost you out-of-network rates or full price.
For Medicare Advantage plans, the network is the plan's list of contracted doctors and hospitals. For Original Medicare with a Medigap plan, there is no network. Any doctor that takes Medicare is in network.
Always look up every doctor you see in the plan's online directory. Even better, call the doctor's office and ask if they take the specific plan you are considering. See our guide on keeping your doctor.
2. Are my prescriptions on the formulary?
Each Medicare plan with drug coverage has a list of covered drugs called a formulary. Your medication may be on the list at a great copay. It may be on the list at a high copay tier. Or it may not be on the list at all.
Run every drug you take through the plan's formulary before you enroll. Check the tier for each drug. Total annual drug cost should be one of your top three factors. Read our Part D plan guide for more.
3. What is the total annual cost, not just the premium?
The cheapest premium is rarely the cheapest plan. A plan with a $0 premium might end up costing $3,000 a year in copays. A plan with a $50 monthly premium might end up costing less overall.
Add up the premium, plus the yearly deductible, plus the expected copays for your doctor visits, plus what you will pay at the pharmacy for your drugs. That total is the real number.
4. What is the maximum out-of-pocket limit?
Every Medicare Advantage plan has a maximum out-of-pocket limit, called MOOP. Once you hit it, the plan pays 100 percent for the rest of the year.
For 2026, MOOP can be up to $9,250 in network. But many plans set theirs lower at $4,500 or $5,500. That number is your worst-case year. A plan with a $4,500 MOOP and a $0 premium is often a much better deal than a $0 MOOP plan with a $9,250 ceiling.
Original Medicare has no MOOP. That is why most Original Medicare members buy a Medigap plan to cap their exposure.
5. Does this plan require prior authorization for the services I need?
Prior authorization means the plan must approve a service before you receive it. Medicare Advantage plans often require prior authorization for things like MRIs, surgeries, skilled nursing stays, and durable medical equipment.
Original Medicare does not require prior authorization for most services. If you have a chronic condition or expect a major procedure, ask what prior authorization is required and how often the plan approves or denies requests.
6. How does this plan handle travel?
If you travel often or split time between two states, this matters a lot. Original Medicare plus a Medigap plan works in all 50 states with any doctor that takes Medicare. Most Medigap plans also include foreign travel emergency coverage.
Medicare Advantage plans usually have local networks. Some plans cover emergency care nationwide but charge out-of-network rates for routine care outside your home area. See our article on Medicare and travel.
7. What is the rate increase history?
Plans raise prices every year. Some plans raise prices steadily and predictably. Others jump up 15 percent or more in a single year.
For Medigap plans, ask the carrier or your agent what the average yearly rate increase has been for the last 5 years in your state. A plan with low rates today but a history of big increases may not be the bargain it looks like.
8. What is the plan's star rating?
Medicare rates every Medicare Advantage and Part D plan from 1 to 5 stars. The rating covers customer service, member experience, drug pricing, and quality of care.
Higher star ratings usually mean fewer complaints and better service. A 4 or 5 star plan is generally a safer choice than a 3 star plan, even at the same price. Plus, 5 star plans come with a special enrollment window that lets you switch into them outside of normal enrollment periods.
9. Can I switch later if my needs change?
Some plan choices are easy to undo. Others are not. Switching between Medicare Advantage plans is easy every year during the Annual Enrollment Period and during the Medicare Advantage Open Enrollment Period.
Switching from Medicare Advantage back to Original Medicare with a Medigap plan is harder. In most states, you have to go through medical underwriting to buy Medigap after your initial 6-month window. Read our guide on switching back to Original Medicare.
10. Will this plan still be available in my zip code next year?
Carriers add and drop plans every year. A great plan in 2026 may not exist in 2027. While you cannot predict the future, you can look at the carrier's history in your area. Has the plan been offered for several years? Does the carrier seem committed to the market?
This matters most if you are choosing a Medicare Advantage plan with great extras, then planning to lock in long-term. If the plan goes away next year, you may have to scramble to find a replacement.
Bonus question: Who is the agent recommending this plan, and what do they earn from it?
Independent agents who represent every major carrier earn similar commissions across plans. They have no reason to push one carrier over another. Captive agents work for one company and can only sell that company's plans.
If your agent only shows you one plan from one carrier, ask why. The right plan for you is rarely the only plan an agent can sell.
How to actually use this list
Print the 10 questions. Sit down with the plan documents for the plans you are considering. Fill in answers for each one. The plan that scores best across all 10 questions is your plan.
If this feels overwhelming, an independent agent can run all 10 questions for you in about 20 minutes. No fees to you. The agent is paid by the carrier you pick, not by you, and rates are set by Medicare regulations, not by the agent.
