A plan with a low premium and a low deductible is a bad deal if your doctor isn't in its network or your prescription isn't on its drug list. Neither shows up in the price, so it is worth checking every plan on your short list before you choose.
We don't check networks or drug lists: Simplivera compares premiums, deductibles, out-of-pocket limits and cost sharing. It does not know which doctors are in a plan's network or which drugs it covers. Use the steps below for that.
1. Search the plan's provider directory
When you compare plans on HealthCare.gov, each plan links to its provider directory, its summary of benefits and its list of covered drugs. You can also add your doctors, hospitals and other facilities while you shop, and the site shows whether each plan covers them in network. State-run exchanges and insurers' own sites have their own directories.
- Search for each doctor by name, and check that the listing matches the office you actually visit.
- Check the hospital you would use, and any specialist you see regularly.
- Make sure you are searching the directory for the exact plan, not the insurer in general. One insurer may sell several plans with different networks.
2. Call the doctor's office
Directories can be wrong. When CMS reviewed Medicare Advantage plans' online directories in 2017 and 2018, 48.74% of the 10,504 provider locations it checked had at least one inaccuracy, such as a provider not at the listed location, or not accepting new patients when the directory said they were. So treat the directory as a starting point and confirm with the office.
- Give them the insurer and the plan's full name, and the network name if the plan lists one. “Do you take Blue Cross?” is not the same question.
- Ask whether they will be in that plan's network for the coming plan year, and whether they are taking new patients.
3. Check the drug list
Each plan has a drug list, also called a formulary. Look up every prescription you take, by name and dose. Three things matter:
- Is it on the list at all? A drug that isn't is generally not covered.
- Which tier is it on? Drug lists are split into tiers, and the tier sets what you pay. Generics are often on the cheapest one.
- Does it carry a rule: prior authorization (the plan must approve it first), a quantity limit, or step therapy (trying a cheaper drug first)?
Check that your pharmacy is in the plan's network too. If a drug you need isn't covered, every marketplace plan has an exceptions process your doctor can use to ask for it.
Recheck every year: Plans update their drug lists regularly, and doctors can join or leave a network. A plan that covered your doctor and your prescriptions this year may not next year, even if you keep the same plan.
Once your short list passes this check, compare the plans on cost on the plan explorer. For a Medicare plan, the same steps apply; see also Medicare Advantage vs. Original Medicare, since the two handle networks very differently.
Sources: HealthCare.gov: before you pick a plan; HealthCare.gov: getting prescription medications; CMS: understanding your drug coverage (PDF); CMS: online provider directory review, round 3 (PDF).