How to Check Your Doctors and Drugs in a Medicare Plan

Before you choose a Medicare plan, check two things for the coming year: that every doctor, specialist and hospital you rely on is in the plan's network, and that every prescription is on the plan's formulary at a cost you can live with. Use the plan's 2027 provider directory and drug list, or the Medicare Plan Finder on Medicare.gov, then confirm with your doctor's office by phone, because directories can lag behind reality. With Original Medicare and a supplement, the doctor check is simpler: ask whether the office accepts Medicare. This guide shows you how to do both checks properly.

Start with a complete list

Everything else is easier once you have this written down:

• Every doctor you see, with the practice name and office address. Many East Valley doctors practice at more than one location, and networks can differ by location.
• The hospital or health system you would want to use for a planned surgery or a hospital stay.
• Specialists you see occasionally, such as a dermatologist, cardiologist or eye doctor.
• Every prescription: the exact name, strength, dose and how many you take a month.
• The pharmacy you use, a backup pharmacy, and whether you would use mail order.
• Any medical equipment or supplies you use regularly, such as diabetic testing supplies or a CPAP.

Checking doctors in a Medicare Advantage plan

• Search the plan's provider directory for the 2027 plan year, not the current year. Search by the doctor's name and the specific office location.
• Call the doctor's office and ask the billing staff: 'Will you be in network with this exact plan, by name, for 2027?' Front desks sometimes answer for the insurance company rather than the specific plan, and one company can run several plans with different networks.
• Check your hospital the same way, and ask whether the specialists you see practice there.
• In an HMO, check whether you need a referral to see each specialist, and whether your current specialists accept referrals from the primary care doctor you would choose.
• In a PPO, if a doctor is out of network, look up what out-of-network visits would cost you and confirm the doctor will see you and bill the plan.

Checking doctors with Original Medicare and a supplement

With Original Medicare, there is no network. Ask the office whether they accept Medicare, and ideally whether they accept Medicare assignment, which means they agree to take the Medicare-approved amount as full payment. A Medigap policy follows Medicare, so if Medicare pays, your supplement pays its share.

Doctors who accept Medicare but not assignment can charge up to 15 percent more than the approved amount (an excess charge). Medigap Plan G covers excess charges; Plan N does not. A handful of doctors opt out of Medicare entirely, and neither Medicare nor a supplement pays them, so it is worth asking.

Checking your prescriptions

For each plan you are considering, check every drug for the 2027 plan year:

• Is the drug on the formulary? Look for the exact strength and form you take.
• Which tier is it on, and what is the copay or coinsurance at your pharmacy?
• Are there restrictions: prior authorization (PA), step therapy (ST) or a quantity limit (QL)?
• Does the plan have a deductible, and does it apply to the tier your drug is on? For 2027 the deductible can be no more than $700 (CMS CY2027 Rate Announcement).
• Is your pharmacy in network, and does it offer preferred cost-sharing? The same drug can cost noticeably less at a preferred pharmacy.
• What is the 90-day or mail-order price, if you take the drug long term?

Using Medicare Plan Finder well

Medicare's Plan Finder at Medicare.gov lets you enter your ZIP code, your drugs and your pharmacies, then compare estimated yearly drug costs across plans. It is the most complete public tool for comparing every plan in your area.

A few tips: create an account or save your drug list so you do not retype it; enter your actual pharmacy, not a generic one; sort by estimated total yearly cost (premiums plus drug costs), not by premium; and open the plan details to see restrictions on each drug. For 2027 plans, use a 2027 search, since the tool shows both years during the fall.

Reading the results: what usually matters most

Common traps

Most of these traps share a cause: comparing plans from memory instead of from a written list. Keep your doctor and drug list in one place, update it whenever something changes, and bring it to every plan review. When you call a doctor's office, write down the date, the person you spoke with and the exact plan name they confirmed. If a directory turns out to be wrong after you enroll, that note helps when you contact the plan or 1-800-MEDICARE.

If you help a parent with Medicare, ask to be added as an authorized contact with the plan and with Medicare, so offices can speak with you when you call on their behalf.

• Checking the current year's directory or formulary when choosing next year's plan.
• Trusting a "we take that insurance" answer without naming the specific plan.
• Forgetting a drug you take only occasionally, like an inhaler or a seasonal prescription.
• Choosing a plan with a low premium and missing a high deductible on your main drug's tier.
• Assuming a brand drug and its generic are covered the same way.
• Not rechecking after a new diagnosis or a new prescription mid-year.

Let us run the checks with you

At Rise Up Benefits Group, this is the first thing we do with every Medicare client in Chandler and the East Valley: we take your list of doctors and prescriptions and check them against the 2027 plans we offer in your county, then call offices when a directory answer is unclear. We do not offer every plan available in your area; Medicare.gov and 1-800-MEDICARE can show you all of your options.

---

The bottom line

A plan is only as good as its fit with your doctors and your prescriptions. Make a complete list, check the 2027 directory and formulary for each plan, confirm with your doctors' offices by phone, and compare total yearly cost rather than premium. Do it again every fall, because networks and drug lists change each January.