How to check your doctors and prescriptions before you enrol

Almost every bad plan experience traces back to the same root cause: nobody checked the network and the formulary properly before enrolment. It is unglamorous work. It is also the work that decides whether the plan fits.

Build the list first

Before you look at a single plan, write down what you are actually protecting. Not from memory — from your records, because memory reliably omits the specialist you saw twice last year.

• Every doctor by full name and the clinic or group they practise under
• Any specialist you have seen in the last two years, even if you do not expect to go back
• The hospital you would want to use, and the one your doctors admit to — these are sometimes different
• Every prescription with the exact dosage and how often you take it
• Your pharmacy, plus whether you would consider mail order

Checking doctors: where people go wrong

Search the plan's own provider directory for the coming plan year, not a general web search and not last year's directory. Then verify the three things that a directory listing alone does not tell you.

• The doctor is in network for the specific plan you are considering — not merely "accepts Medicare" and not in network for a different plan from the same carrier
• The specific clinic location is in network — large groups are sometimes contracted at one site and not another
• They are accepting new patients under that plan, if you are not already established

Checking prescriptions: the part that costs real money

A formulary is the plan's list of covered drugs, arranged in tiers. The tier drives your cost far more than the plan premium does. Two plans with identical premiums routinely differ by hundreds or thousands of dollars a year for the same person, purely on tier placement.

For each medication, check four things: is it on the formulary at all, what tier is it on, what does it cost at your pharmacy, and are there restrictions.

• Prior authorisation — the plan must approve it before covering it
• Step therapy — you must try a cheaper drug first
• Quantity limits — a cap on how much is covered per fill

Compare total yearly cost, not premiums

Once you have checked the drugs, build one number per plan: the annual premium, plus any deductible, plus your expected copays across the year for the medications you actually take.

This is the number that tells you which plan is cheaper. Ranking plans by premium is how people end up on a plan that costs them more, and it is the most common avoidable mistake in Part D.

A worked example of why this matters

Two Part D plans, both $18 a month. Plan A puts your maintenance medication on tier 2 with a modest copay and no restrictions. Plan B puts the same drug on tier 4 with coinsurance, requires prior authorisation, and prices it best at a pharmacy you would have to drive across town for.

On premium they are identical. Across a year they are not remotely close. Nothing on the plan summary page would have told you that — you have to check the drug.

Do it again every autumn

Networks and formularies are reset annually. A plan that was perfect this year can move your medication to a higher tier or drop your specialist for January, and the only warning is the Annual Notice of Change that arrives in September.

So this is not a one-time exercise. It is a yearly one, during the Annual Enrollment Period, and it takes far less time the second year because the list already exists.

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The bottom line

If you do nothing else before enrolling, do this. And if you would rather have someone do it with you — entering each drug, checking each doctor, and showing you the comparison — that is precisely the work Sarah does before anyone signs anything.