How to know what’s covered before you sign up for a Medicare plan

I get the question “Is this covered?” all of the time. Get tips to figure out what’s covered by your Medicare plan.

“Is this covered?” It’s one of the most common questions I get from members wondering about seeing a new doctor, changing medicines or trying a new treatment option. And I’m glad they call and ask me. Knowing what appointments, tests, screenings and other services your Medicare plan coverage pays for, is the first step to understanding how much you’ll have to pay for your health care.

What “covered” means

If something is “covered,” it means your Medicare plan will help you pay for it. How much the plan pays depends on the type of care you use and where you get it. To get the most cost effective health care, you’ll want all the services you use to be covered by your Medicare plan.

  • Some covered services are completely free to you, like going to the doctor for preventive care screenings and tests. Your plan pays everything.
  • For others – like seeing the doctor for a lingering sinus infection or filling a prescription for covered antibiotics – you’ll pay a fee. The amount you pay will be different depending on the type of plan you have and whether or not you’ve taken care of the amount you have to pay before your plan starts helping you (your deductible).

Checking what’s covered

Each plan has a few areas to keep in mind when checking coverage:

Doctors

Medicare plans cover specific doctors, specialists and clinics, often referred to as a network. There are ways to find quality doctors who also offer the most coverage when you see him/her.

  • How to check what’s covered:

    • Original Medicare: Use the Medicare.gov website to look up the doctor, other provider, clinic or hospital you want to use. When you call to make an appointment, confirm that they accept Medicare.
    • Medicare Advantage plans and Cost plans: Call the insurance company to make sure the doctors you want to see are covered by the plan you’re interested in. You can also check the plan’s website to see if they have an online search tool to find a covered doctor or clinic. Once you’re a member, you can usually log in to your online account to search for covered doctors and clinics in your network.

Medicines

Plans have a list of medicines, called a formulary, which shows what medicines they cover. The list can give you a general idea of what you may pay for your medicines.

  • How to check what’s covered: Make a list of your prescriptions, and then call the insurance company with the plan you’re interested in to see if they’ll help pay for your medicines. You can also look at the plan’s website for an online formulary search tool to check if your medicines are covered.

Different medicines are covered differently. For example, generic medicines are usually less expensive than brand-name medicines. So ask how much you’ll have to pay, and make sure it fits your budget. If it’s too expensive, your doctor can help you find a different drug, or the pharmacy might have a rewards or payment program.

Services

From doctor visits and physical therapy sessions to blood tests, X-rays, ambulance rides and hospital stays, Medicare plans cover health care services differently.

  • How to check what’s covered:
    • Original Medicare: Use the Medicare.gov website to look up the test, item or service and see how much you may need to pay.
    • Medicare Cost, Medicare Advantage or Supplements: Call the insurance company to ask whether they help pay for the things that are important to you. You can also ask for the plan’s standard document that shows what they cover, called an Evidence of Coverage.