Key Takeaways

• Many Medicare Advantage plans appear nearly identical on the surface, but key differences in coverage, networks, and costs often reveal themselves only upon deeper inspection.

• In 2025, evaluating the fine print and comparing plan elements like prior authorization rules, out-of-network flexibility, and supplemental benefits is essential before enrollment.

The Appearance of Similarity Across Plans

At first glance, the best Medicare Advantage plans often seem to mirror each other. Whether you’re comparing them in your local area or across state lines, many plans list similar features:

• Hospital and medical coverage bundled into one plan

• Part D prescription drug coverage included

• Extra benefits like dental, vision, or hearing

• Out-of-pocket maximums that protect against catastrophic costs

With such standard offerings, you might be tempted to think that all 4.5- or 5-star rated plans (as assigned by the Centers for Medicare & Medicaid Services, or CMS) are equally strong choices. But that would be a mistake.

The CMS rating system evaluates overall quality and performance based on 38 different measures, but it doesn’t always capture how well a plan fits you. What looks good in a brochure may fail to meet your needs in practice unless you examine the finer details.

What Star Ratings Actually Reflect

In 2025, the CMS Star Ratings still range from 1 to 5 stars, with 5 being excellent. These ratings are updated each year and reflect:

• Member experience and satisfaction

• Management of chronic conditions

• Preventive service delivery (like flu shots or screenings)

• Customer service quality

Plans with 4 stars or higher are generally considered top-tier. However, CMS does not rate every detail equally, and the star system focuses more on system-wide performance than personalized suitability. Two plans with the same star rating may have entirely different networks, costs, and rules.

This is why digging into the specifics matters.

Network Differences Can Limit Access

Many Medicare Advantage plans use managed care models like Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). In both cases, provider networks play a major role in how and where you can receive care.

• HMOs require you to use in-network providers except for emergencies. You typically need a referral to see a specialist.

• PPOs allow out-of-network care, but at a higher cost. Referrals are often not required.

So, even if two plans have the same rating and similar benefits, your experience could be drastically different based on your doctor’s inclusion in the plan’s network.

You should always confirm:

• Whether your current primary care physician participates in the plan

• If your local hospital is in-network

• Whether specialists you rely on are covered

Failure to verify the network can result in unexpected costs or disrupted continuity of care.

Prior Authorization Rules Vary Widely

Another crucial point of comparison is prior authorization. This is when your plan requires you to get approval before receiving certain services, procedures, or medications.

Some Medicare Advantage plans require prior authorization for:

• High-cost imaging (MRI, CT scans)

• Durable medical equipment

• Skilled nursing facility stays

• Certain prescription drugs

While all plans use prior authorization to some degree, the extent and strictness of these requirements can differ.

In 2025, CMS is continuing to enforce transparency rules for prior authorization, including response time limits. But plans still retain discretion in how many services they subject to this process. A plan with excessive prior authorization hurdles can delay treatment or add administrative burdens.

Out-of-Pocket Costs Beyond Premiums

While all Medicare Advantage plans cap your annual in-network out-of-pocket costs (in 2025, this can be as high as $9,350), what you pay along the way varies dramatically.

You should compare:

• Deductibles: Some plans have no deductible for medical services, while others do.

• Copayments and coinsurance: These can differ for doctor visits, hospital stays, and outpatient care.

• Prescription drug tiers: Plans assign medications to different tiers, and your copay can range from a few dollars to hundreds depending on the tier and pharmacy used.

Even plans with the same out-of-pocket maximum can feel very different depending on how quickly you reach that limit.

Supplemental Benefits Aren’t Always Equal

Many people are drawn to Medicare Advantage because of the extra perks. In 2025, most plans offer at least a few of the following:

• Vision exams and glasses

• Hearing aids

• Routine dental cleanings

• Fitness programs

• Over-the-counter allowances

However, the scope and value of these benefits can vary significantly:

• One plan may cover only basic dental cleanings twice a year, while another covers fillings and dentures.

• Some fitness benefits may include gym memberships, while others offer only online classes.

• Over-the-counter allowances can range in value and usability.

Be sure to review:

• The frequency and scope of the benefit

• Any restrictions on providers or locations

• Dollar limits and expiration dates for each benefit

Travel and Emergency Coverage Varies

If you spend time in more than one state or plan to travel during retirement, your choice of Medicare Advantage plan becomes even more important.

HMO plans often do not provide out-of-network coverage for routine services. If you need non-emergency care while away from home, you may have to pay the full cost.

In contrast, some PPO plans offer nationwide networks or out-of-network options that make it easier to maintain care continuity while traveling. However, even PPOs may require you to notify the plan in advance or use certain providers to qualify for lower costs.

Check the specifics of:

• How the plan handles out-of-area emergencies and urgent care

• Whether telehealth options are available while traveling

• If snowbirds or part-time residents are supported

Prescription Drug Coverage Isn’t Uniform

Most Medicare Advantage plans include Part D coverage, but not all formularies (the list of covered drugs) are the same.

Key differences to evaluate:

• Formulary design: Are your current medications covered?

• Tier placement: What is the copay for each medication?

• Preferred pharmacies: Some plans offer lower copays at specific pharmacy chains.

• Coverage rules: Are step therapy or quantity limits in place?

In 2025, there’s a $2,000 annual cap on out-of-pocket costs for covered prescription drugs, which offers significant protection. However, the path to reaching that cap varies by plan and medication usage.

Enrollment and Review Timelines

The best time to assess and compare plans is during the Medicare Open Enrollment Period, which runs each year from October 15 through December 7. Any changes made during this period take effect on January 1 of the following year.

Other key periods include:

• Initial Enrollment Period (IEP): When you first become eligible for Medicare

• Special Enrollment Periods (SEPs): Triggered by life changes such as moving or losing other coverage

• Medicare Advantage Open Enrollment (January 1 to March 31): Allows switching from one Advantage plan to another or going back to Original Medicare

Plan details change annually. Benefits, provider networks, premiums, and drug formularies are updated each year. Even if you’re happy with your current plan, it’s wise to review the Annual Notice of Change (ANOC) sent to you in September.

Why One Size Doesn’t Fit All

Despite how similar many Medicare Advantage plans appear, their differences can affect every aspect of your healthcare experience. From needing a prior authorization for a basic test to discovering your dentist is out-of-network, the fine print matters.

In 2025, CMS is continuing to enhance transparency, improve response times for coverage decisions, and monitor plan performance. But it’s still your responsibility to:

• Assess how each plan matches your healthcare needs

• Compare network access and drug coverage

• Understand cost-sharing throughout the year

• Watch for changes during the annual review window

Personalized Help Can Make a Big Difference

Choosing a Medicare Advantage plan is about more than star ratings or popular buzzwords. What’s best for someone else may not be right for you.

If you’re unsure about comparing plan details or need help reviewing your current coverage, speak with a licensed agent listed on this website. They can offer personalized insights based on your medications, doctors, lifestyle, and budget.

Don’t assume all plans with great ratings are the same. Dig deeper and make a confident, informed decision.