Key Takeaways

• Not all Medicare Advantage plans are created equal. Some of the most important differences lie in the fine print—like out-of-pocket limits, prior authorization requirements, and the true scope of extra benefits.

• In 2025, the structure of Medicare Advantage plans includes new protections, such as the $2,000 annual cap on Part D out-of-pocket costs. But many features still vary by plan, and misunderstanding them could cost you money or access to care.

Start With the Basics, But Don’t Stop There

When you begin comparing Medicare Advantage plans in 2025, you might focus on premiums or advertised perks. However, those details only scratch the surface. You need to understand the entire structure of a plan—especially how it handles medical services, prescription drugs, and cost protections.

Start with these foundational features:

• Type of Plan: HMO, PPO, or PFFS? Each one has different rules for provider access and referrals.

• Coverage Area: Most plans have geographic limits. Make sure your plan covers your state or county and allows access when traveling.

• Star Ratings: CMS rates plans from 1 to 5 stars based on quality and performance. Higher-rated plans often indicate better service and outcomes.

But these basics aren’t enough on their own. You need to look deeper to find what truly sets one plan apart from another.

Out-of-Pocket Costs Still Add Up

Medicare Advantage plans are required to cap your in-network out-of-pocket costs. In 2025, the maximum is $9,350 for in-network services, and $14,000 for combined in- and out-of-network services. But not all plans use the maximum—some have lower caps.

Here’s what you should look for:

• Deductibles: Some plans have no medical deductible, but many still have one for drug coverage.

• Copayments vs. Coinsurance: Know how much you’ll pay for primary care visits, specialists, ER visits, and inpatient stays.

• Tiered Drug Costs: Even with the $2,000 cap under Part D in 2025, you’ll want to know what tier your medications fall under and how they’re priced.

Compare these costs carefully. Two plans with similar benefits can have very different costs depending on how they structure services.

Prior Authorization: A Hidden Barrier to Care

Prior authorization is one of the most significant, and often overlooked, elements of Medicare Advantage plans. It requires your provider to get plan approval before delivering certain treatments or services.

In 2025, CMS has tightened prior authorization guidelines, especially for hospital and skilled nursing care. However, many plans still use it widely for:

• Diagnostic imaging

• Durable medical equipment

• Home health care

• Physical and occupational therapy

When comparing plans, check how often they require prior authorization and how long it takes for decisions to be made. Delays can impact your treatment timeline.

Network Size and Provider Choice

Medicare Advantage plans maintain a list of in-network providers, and going out-of-network can be expensive or not allowed.

• HMOs: Require you to use network doctors and get referrals.

• PPOs: Allow out-of-network use but with higher cost-sharing.

• PFFS Plans: Offer more flexibility but may lack a stable provider network.

Always confirm your doctors, hospitals, and specialists participate in a plan’s network before enrolling. Changes can occur year to year, so don’t assume your current provider will remain in-network.

Prescription Drug Coverage Differences

While most Medicare Advantage plans include drug coverage, the way they structure their Part D benefits varies greatly.

In 2025, key changes have improved drug affordability:

• Annual Out-of-Pocket Cap: $2,000 maximum for covered drugs.

• Insulin Cap: $35 per month maximum under all plans.

• No More Coverage Gap: The infamous “donut hole” is officially gone.

Still, each plan creates its own formulary, with specific tiers and coverage rules:

• Some plans require step therapy or prior authorization for certain drugs.

• Formularies may change annually—a medication covered this year might not be next year.

Compare drug lists side-by-side using the plan’s published formulary, and don’t forget to factor in mail-order options and pharmacy network size.

Supplemental Benefits Sound Nice, But…

Medicare Advantage plans often advertise supplemental benefits like dental, vision, hearing, and even gym memberships. While these perks attract attention, they are not always as generous or widely available as they sound.

• Dental Coverage: Often limited to cleanings, x-rays, and exams. Comprehensive procedures like crowns or implants may not be covered.

• Vision and Hearing: Usually have annual allowances that may not fully cover exams and devices.

• Over-the-Counter (OTC) Benefits: Not all plans offer them, and some restrict usage to specific retailers or products.

Review the coverage details, spending limits, and eligibility conditions for each supplemental benefit. Don’t choose a plan based on one benefit without confirming how it works in practice.

Customer Service and Complaint History

CMS publishes plan performance data, including complaints, disenrollment rates, and responsiveness to members. High complaint rates may indicate issues with claims processing, benefit access, or customer support.

Use Medicare Plan Finder tools to review these data points:

• Disenrollment Rates: How many people left the plan during the year?

• Customer Complaints: Are they rising or falling year-over-year?

• Appeal Outcomes: How often does the plan overturn prior denials on appeal?

Even if a plan has decent benefits, poor service can lead to frustration and delays.

Enrollment and Change Windows in 2025

Timing matters when it comes to choosing or switching a Medicare Advantage plan. In 2025, you have specific windows to act:

• Initial Enrollment Period (IEP): Starts 3 months before you turn 65, includes your birthday month, and ends 3 months after.

• Annual Enrollment Period (AEP): Runs from October 15 to December 7. You can switch, join, or drop a Medicare Advantage plan.

• Medicare Advantage Open Enrollment (MA OEP): January 1 to March 31. Allows current MA members to switch to a different MA plan or return to Original Medicare.

• Special Enrollment Periods (SEPs): Triggered by life events like moving or losing coverage.

Missing these windows can limit your choices, especially if you’re locked into a plan that doesn’t work well for your needs.

What Changed in 2025?

If you’re comparing plans in 2025, be aware of what’s new this year:

• $2,000 Part D Out-of-Pocket Cap: Reduces long-term medication expenses.

• Stricter Prior Authorization Rules: Plans must follow faster and more transparent processes.

• Mid-Year Notifications: You’ll receive notices about unused supplemental benefits between June 30 and July 31.

• Plan Consolidations: Fewer total plans, but more Special Needs Plans (SNPs) available for chronic conditions.

Regulations are evolving to make plans more accessible and accountable, but it’s still your responsibility to examine the differences.

Evaluating the Plan That Works for You

Choosing a Medicare Advantage plan isn’t about picking the one with the flashiest brochure. It’s about:

• Understanding your healthcare needs and budget

• Confirming your providers are in-network

• Comparing out-of-pocket costs beyond premiums

• Checking drug coverage and restrictions

• Reading the fine print on extras

• Investigating plan ratings and complaints

Don’t rely on assumptions. Use official plan materials, the Medicare Plan Finder tool, and help from a licensed agent listed on this website to make your decision.

Take Control of Your Coverage Decision

Medicare Advantage plans may seem similar at first glance, but the differences that truly matter often lie in the details. If you want peace of mind in 2025, it’s critical to dig deeper and understand what you’re really getting.

Don’t leave this decision to chance. Reach out to a licensed agent listed on this website for one-on-one help reviewing your options and understanding your benefits before enrolling.