Medicare Cost Scenario Planner Tool

Key takeaway: Before you pick any Medicare plan, check whether your actual doctors are in-network and your actual medications are on the formulary — because a plan with a low premium can end up costing you thousands more per year if your doctor is out-of-network or your drug is on the wrong tier.

What this helps you decide

• Whether your current primary care doctor, specialists, and other providers are in-network for the Medicare Advantage plan you're considering
• Whether your prescriptions are covered under a plan's formulary, and at what cost tier — Tier 1 generics and Tier 4 specialty drugs can be hundreds of dollars apart per month
• Whether Original Medicare plus a standalone Part D plan might give you better access to the specific doctors and drugs you rely on
• Which plan type — MA-HMO, MA-PPO, or Original Medicare with Medigap — is the best fit given your specific healthcare needs today

Who this is for

• Someone who has seen the same primary care doctor and specialists for years and is not willing to switch to new providers just to save on a monthly premium
• A person managing a chronic condition — diabetes, heart disease, cancer, COPD — who takes brand-name or specialty medications and needs to know the real annual drug cost before enrolling
• Anyone during Medicare's Annual Enrollment Period (October 15 – December 7) who is considering switching plans and wants to verify the new plan covers their care before making the change
• A new Medicare enrollee who currently has employer coverage and needs to understand whether their existing care team will still be available under Medicare

Example results

Example 1 — Primary care in-network, specialist out-of-network. Let's say you sign up for a Medicare Advantage HMO plan because the $0 premium looks great. Your primary care doctor is in the network — so far, so good. But your cardiologist, who you've been seeing for three years, is not. With an MA-HMO plan, you can't see out-of-network providers except for emergencies. That means you either find a new cardiologist in the plan's network or you pay the full bill yourself. If you manage to get a referral to an in-network cardiologist, expect copays of $20–$40 per visit. If you insist on keeping your current cardiologist outside the network, you could pay $100–$300 or more per visit with no coverage applying. Four specialist visits per year at that rate adds up to $400–$1,200 in costs your plan won't touch. That's the hidden cost of not checking the provider directory before you enroll.

Example 2 — Same drug, two very different costs. You take Eliquis, a brand-name blood thinner. It doesn't have a generic equivalent, so you're stuck with the brand. Here's how the same drug plays out across two Part D plans: Plan A places Eliquis on Tier 4 (specialty tier), and your share of the cost is $95 per month. Plan B places it on Tier 3 (preferred brand), and your share is $47 per month. Same drug. Same 30-day supply. A $48-per-month difference, which works out to $576 per year. Over five years that's nearly $2,900 in extra costs — all because Plan A's formulary placed the drug on a higher tier. The plan premium comparison made Plan A look slightly cheaper. But it wasn't, not for you.

Example 3 — A clean match across the board. You have three doctors: a primary care physician, a rheumatologist, and a dermatologist. You take five medications: two generics for blood pressure, one generic for cholesterol, one low-cost brand for thyroid, and one over-the-counter supplement. You run every provider through the plan's directory and every drug through the formulary. All three doctors are in-network. All five medications are on the formulary, four at Tier 1 (generic, $3–$10 copay) and one at Tier 2 (preferred generic, $15–$25 copay). This is a strong coverage match. Your out-of-pocket risk is low, your care team stays intact, and the plan's monthly costs are predictable. This is exactly the outcome you want from this assessment before enrolling.

Sample scenarios

Scenario	Doctor/Drug Status	Estimated Impact
MA-HMO: specialist out-of-network	PCP in-network, cardiologist NOT in-network	$400–$1,200/yr in uncovered specialist costs or forced provider change
Brand-name drug: tier placement difference	Eliquis on Tier 4 vs. Tier 3 across two plans	$576/yr difference ($95/mo vs. $47/mo copay) for the same drug
All doctors and drugs: full coverage match	3 providers in-network, 5 drugs on Tier 1–2	Low out-of-pocket risk; plan costs are predictable and well-matched
Original Medicare + Medigap: no network restriction	All Medicare-accepting providers covered nationwide	No network access concerns; drug costs managed via standalone Part D plan

What to do next

1. Make a list of every provider you see. Write down your primary care doctor, every specialist, your preferred hospital, and any lab or imaging center you use regularly. Then look up each one in the plan's online provider directory — don't assume, check.
2. Pull your current prescription list. Get the exact drug names (brand and generic), dosages, and how often you fill them. Then search each drug in the plan's formulary. Note the tier for each drug and the cost-sharing at that tier. Do this for every plan you're seriously considering.
3. Compare total annual drug cost, not just the monthly premium. Add up what you'd actually pay per year under each plan: (monthly premium × 12) plus your estimated copays for all your medications. A plan with a $0 premium but high drug tiers often costs more than a plan with a $28/month premium and better formulary placement.
4. If any doctor or drug is a dealbreaker, filter first. Before comparing premiums, costs, or benefits, eliminate any plan that doesn't cover your must-have doctors or medications. Start with coverage, then compare costs among the plans that clear that bar.

Key facts

• A plan's formulary determines what drugs are covered and at what cost tier — the same brand-name medication can cost two to three times more on a Tier 4 specialty listing than on a Tier 3 preferred brand listing, with no difference in the drug itself.
• Provider networks change annually — a doctor or specialist who is in-network this year may not be in-network next year, which is why checking coverage at every Annual Enrollment Period matters even if you've been on the same plan for years.
• Checking coverage before enrolling prevents the most common and costly Medicare mistakes — choosing a plan based on premium alone without verifying provider and drug coverage is the single biggest source of unexpected out-of-pocket spending for Medicare enrollees.

Related decisions

• Part D plan shopping tool — find the lowest total annual drug cost for your specific medications
• Medicare Advantage vs. Medigap cost comparison — see which plan type fits your budget and health needs
• Travel and network risk assessment — understand how your coverage works when you're away from home
• Medigap fit assessment — find out if Medigap's predictable costs and nationwide access are right for you