Health plans with drug coverage

Tips on picking the best plans

Explore details of health plans with drug coverage in the chart below, and check out these guides:

• Our tips for navigating this year's choices
• A step-by-step guide
• Stand-alone drug plans in detail

What’s in the chart below

• Type: The chart shows four types of health plans with drug coverage — HMO, PPO, HMO-POS, PFFS. They’re explained below.
• Premium: The monthly charge for the plan. This is in addition to whatever monthly Part B payment you make to Medicare.
• Part B rebate: Some plans pay part of your monthly Part B premium, which for most people will be $99.90 per month.
• Doctor copay: This is your cost every time you see a doctor. The first dollar figure is for primary care physicians, the second is for specialists. Costs are listed for physicians inside the network (Net:) and outside the network (Out:).
• Hospital copay: This is your cost for inpatient hospital care, for each admission. Costs are listed for hospitals inside the network (Net:) and outside the network (Out:).
• Estimated total cost: This is Medicare’s horseback estimate of your annual out-of-pocket costs if you select this plan, including your Part B premium and drugs. It is based on an average person in good health and could vary greatly, depending on the drugs you take and your general health condition. The only good way to compare plans’ costs for your particular circumstances is with Medicare’s Plan Finder on www.medicare.gov.
• Out-of-pocket cap: Your maximum payment for the year inside the network (Net:) and outside the network (Out:). The lower the cap the better.
• Network size: The total number of providers in a network, including doctors, hospitals, nursing homes and other services. Some networks cover just a county, others a whole region, others the entire state.
• Generics in the gap: Whether a plan pays for generic drugs in the coverage gap, or “doughnut hole,’’ which begins when total drug costs hit $2,970 and ends when your out-of-pocket costs reach $4,750.

What’s not in this chart

• Special Needs Plans (see explanation below)
• Copayments for other services: Plans usually charge copayments for drugs, skilled nursing homes, ambulances, emergency rooms and many other services. Check individual plans for these details.
• Goodies: Some plans offer some dental, hearing and vision coverage, exercise classes, transportation to the doctor and other extra benefits. Check plans for details.
• Health plans without drugs: A few plans are cheaper because they do not offer drug coverage, but choosing those plans can result in stiff penalties in subsequent years unless you receive comparable drug coverage elsewhere.

Health plans: how they differ

Medicare allows several types of private health plans, which cover all your care. Here is how they differ:

• HMO (Health Maintenance Organization): Generally require you to use providers within a network, unless an emergency forces you to seek treatment elsewhere. A personal physician usually coordinates your care and must approve visits to specialists.
• PPO (Preferred Provider Organization): Also encourages you to use providers within a network, with low copayments, but also allows you to use providers outside the network at a higher cost. Usually allows you to see specialists within the network without prior approval of a personal physician. “Regional’’ PPOs generally have larger networks, such as the entire state. Some bigger companies allow you to use their PPOs in other states, useful to snowbirds. Verify before signing up.
• HMO-POS (HMO-Point of Service): A hybrid between an HMO and PPO. Usually requires you to stay within a network and seek approval of a personal physician before seeing network specialists. But also may cover some care outside the network, with a referral. Some POS plans approve very little coverage outside the network, so check plans for details.
• PFFS (Private Fee for Service): Has network, but also allows members to get care outside the network if the provider will accept the plan’s payment. Make sure provider will accept payment before incurring bills.
• Special Needs Plans: People with certain chronic conditions like diabetes and COPD can sometimes qualify for a Special Needs Plan, which may include extra services for managing their disease. Make sure you qualify before purchasing. People living in nursing homes may also qualify for special plans, as can poor people who qualify for both Medicare and Medicaid. These plans are not listed in the chart because only some people qualify. To compare Special Needs Plans, go to Medicare’s Plan Finder at www.medicare.gov. In Step 4, which asks if you want to Refine Your Results, look at lower left for button that says Select Special Needs Plans, mark the type of plan that interests you, then proceed to the results page.