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How to know if your Medicare Plan is Working for You

On January 1, new Medicare Advantage plans (or changes to your existing Medicare Advantage plan) will go into effect. As your plan gets rolling, it’s a good idea to pay attention to how it is working for you. Think about the things that matter the most to you (such as coverage for specific services or prescription drugs) and evaluate whether the plan is meeting your needs. We’ve compiled a list of five things to look out for to make sure your plan is working for you.

How to know if your Medicare Plan is Working for You


There are several factors that go into choosing the right Medicare plan for you. You will know it’s working well for your needs if the following five things are true:


1. Your doctors are in-network


If you are enrolled in a Medicare Advantage plan, it’s best to seek health care services from a medical provider or hospital that is in your plan’s network. Seeking care from out-of-network physicians typically comes with higher out-of-pocket costs. Anyone who had private employer health insurance before they switched to Medicare will be familiar with health provider networks. You should be able to create an online account with your health plan to run a search for in-network providers. Your Medicare agent may also be able to confirm that your preferred providers are part of your plan’s network.


2. The prescription drugs you take are covered by the plan’s drug formulary


Each Part D prescription drug plan or Advantage plan with prescription drug coverage has a drug formulary, which is a list of drugs that are covered. Generally, drug plans have four tiers with three price points:

1. Tier one drugs come with the lowest co-payment and are typically generic drugs (the non-name brand version of drugs).

2. The second tier of drugs comes with a medium co-payment and typically includes the more affordable brand name drugs.

3. The third tier of drugs have the highest co-payment and are often brand-name drugs that have a generic version available.

4. The fourth tier of drugs are usually specialty drugs used to treat serious illnesses such as cancer that come with a high cost.


Your prescription drug plan formulary should include your regular prescription drugs, preferably with affordable copays and generic options.


3. The plan covers services that are important to you


One of the main reasons for signing up for a Medicare Advantage plan over Original Medicare is that plans usually cover services that Original Medicare doesn’t cover. Some examples are:

  • Hearing

  • Dental

  • Vision

  • Prescription drugs

  • Transportation to doctor’s appointments

  • Wellness programs

If your Advantage plan is covering the additional services that are important to you, then you have picked a plan that is meeting your needs.


4. The plan is reducing your out-of-pocket expenses


Unlike Original Medicare, Advantage plans come with an annual out-of-pocket maximum that can help control total healthcare spending over the course of a calendar year. The additional services covered by Advantage plans can also greatly reduce out-of-pocket spending for dental treatments, hearing aids, and prescription drugs, etc. If your plan is providing cost savings in one or more ways, then it is doing its job.


5. You are getting the customer service you need


It’s natural that you will have questions about a bill or your coverage options from time-to-time. Your plan should provide appropriate customer service in one or more ways (phone, email, online chat, etc.) so you can get any issues resolved, have your questions answered, and make the best use of your coverage. Your Medicare agent may also be able to help you resolve issues and answer your questions.



Our independent insurance agents are dedicated to assisting people on Medicare and those who are ready to transition from employer coverage to personal retirement coverage. We help kupuna understand their benefits options and apply for additional coverage, as needed. We are the only insurance agency in Hawaii contracted with EVERY Medicare Advantage plan, which means we are able to offer unbiased advice; all at no cost to our clients.


At PBC, our clients are our number one priority and we look forward to getting to know you and your needs. Call us today at (808) 738-4500 to see how we may be of assistance.

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