When you first become eligible for Medicare, one of the most important decisions you’ll make is whether to stay with Original Medicare or choose a Medicare Advantage plan. Understanding the difference helps you avoid costly surprises and pick coverage that fits both your needs and your budget.
What Is Medicare Advantage?
Medicare Advantage (also known as Part C) is an alternative to Original Medicare. These plans are offered by private insurance companies approved by Medicare. They cover everything that Original Medicare (Part A and Part B) does, but often wrap in extra benefits that go beyond basic hospital and doctor coverage.
The big advantage for many people? Medicare Advantage plans often include prescription drug coverage (Part D), dental, vision, hearing, and sometimes wellness programs, all bundled into one card. This simplified setup can reduce paperwork and make it easier to manage all your benefits in one place.
Original Medicare vs. Medicare Advantage
Original Medicare includes Part A (hospital insurance) and Part B (medical insurance). To get prescription drug coverage, you must enroll in a separate Part D plan. You’re also responsible for 20% of most outpatient services, with no out-of-pocket maximum unless you buy a Medigap policy (which is also separate).
Medicare Advantage combines Part A, Part B, and usually Part D into a single plan. It limits your maximum annual out-of-pocket costs, which can help protect you from large medical bills.
If you like the idea of one plan handling everything — doctor visits, hospital stays, and prescriptions — Medicare Advantage might be a better fit.
Where Prescription Drug Coverage Fits In
Most Medicare Advantage plans include prescription drug coverage. That means you don’t need to shop separately for a Part D plan. These plans are called MAPD (Medicare Advantage Prescription Drug) plans.
But not all Medicare Advantage plans include drug coverage. If you pick a plan without it, you may not be able to enroll in a stand-alone Part D plan later without penalties, depending on the plan type. It’s critical to look at what’s included before enrolling to avoid gaps in coverage or extra costs down the line.
Prescription coverage inside a Medicare Advantage plan comes with its own list of approved medications (called a formulary) and rules about where and how you pick up your prescriptions.
Which Medicare Advantage Plans Include Prescription Drug Coverage? (2025)
HMO (Health Maintenance Organization) Plans
Usually include Part D coverage and require you to stick with a network of doctors and pharmacies, except in emergencies.
PPO (Preferred Provider Organization) Plans
Also often include prescription drugs and give you more flexibility to see out-of-network providers for a higher cost.
SNP (Special Needs Plans)
Designed for people with certain health conditions or financial limits. These plans always include drug coverage because of the specific needs they serve.
But not every Medicare Advantage plan includes drugs. Some plan types, like Medical Savings Accounts (MSAs), never offer Part D. Others may give you the option to add a separate drug plan — but don’t count on that always being available.
How Drug Coverage Is Integrated
When you enroll in a MAPD plan, your drug benefits are part of your single plan card. You’ll fill prescriptions based on that plan’s formulary, which is a list of covered medications broken into different tiers. Each tier has its own pricing rules and copays.
Plans also set coverage rules that can affect your cost or access — things like step therapy, prior authorizations, or requiring certain pharmacies. These rules can vary widely.
What to Watch For Every Year
Medicare Advantage plans (and their drug coverage) change each year. Formularies may drop certain medications, shift drugs into higher copay tiers, or change which pharmacies are considered preferred. That means the plan you picked last year might not be the best choice this year — even if the name looks the same.
To avoid surprise costs, always review the Annual Notice of Change. Confirm your prescriptions are still covered, check the out-of-pocket drug costs, and make sure your pharmacy is still in-network. Taking time now can save headache and money later.
How to Compare Medicare Advantage Plans: A Step-by-Step Checklist (2025)
1. Review the Total Costs, Not Just Monthly Premiums
Look at the full picture — premiums, deductibles, copays, coinsurance, and out-of-pocket maximums.
2. Make Sure Your Doctors and Hospitals Are in the Plan’s Network
Confirm your preferred doctors, clinics, and hospitals are in-network. HMO plans require you to stay in-network, PPO plans offer more flexibility at higher costs.
3. Verify Prescription Drug Coverage Matches Your Needs
Check the formulary, pharmacy network, and coverage rules to make sure your medications are covered affordably.
4. Evaluate Extra Benefits
Dental, vision, hearing, and other perks are nice, but don’t let them distract from medical and drug coverage.
5. Check Member Support and Customer Service
Good support matters when billing or coverage issues come up. Look at reviews and plan reputation.
6. Review Plan Documents Carefully
Read the Summary of Benefits and Annual Notice of Change. These spell out what’s covered and what’s changing.
Avoiding Common Pitfalls and Misleading Medicare Marketing
Red Flags in Medicare Marketing
Watch out for too-good-to-be-true promises, unsolicited calls, and high-pressure sales tactics.
How to Protect Yourself
Verify sources, ask direct questions, and request everything in writing.
Stick With Trusted Resources
Use official Medicare tools or trusted agents who focus on education and long-term support, not quick sales.
Choosing the Right Medicare Agent: What to Look For and Why It Matters
Qualities That Set a Good Agent Apart
Look for patience, transparency, deep knowledge, and ongoing support.
Salesperson or Advocate?
Good agents listen, explain clearly, and help you compare plans side by side without pressure.
Why It Matters
Medicare decisions affect your health and finances. Choosing the right agent ensures ongoing support, not just enrollment help.
Maintaining and Reviewing Your Medicare Advantage Plan Year-Round
Don’t Put Your Plan on Autopilot
Plans change every year. Check your Annual Notice of Change and confirm your providers and prescriptions remain covered.
Use Your Agent as a Year-Round Resource
A reliable agent helps you navigate updates, answer questions, and make adjustments as needed.
Annual Enrollment Is Your Safety Valve
From October 15 to December 7, you can switch plans if needed. Reviewing proactively helps avoid surprises in January.
Download Our Free Checklist
Want a printable version of the Open Enrollment checklist?
Includes
- Timeline with all important dates
- Document checklist
- Questions to ask before choosing a plan
- Comparison worksheet
- Contact information for resources
Print it out. Check off items as you go. Make notes in the margins.
